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psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died
September 30, 2020 - Book/Report
Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.
Citation Text:
Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Repor…
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psnet.ahrq.gov/issue/intimidation-practitioners-speak-about-unresolved-problem
September 26, 2017 - Study
Intimidation: practitioners speak up about this unresolved problem.
Citation Text:
Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4.
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hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit2_1.jsp
January 01, 2009 - Facts and Figures Exhibit 2.1
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psnet.ahrq.gov/issue/diagnostic-errors-hospitalized-adults-who-died-or-were-transferred-intensive-care
October 13, 2021 - Study
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
Citation Text:
Diagnostic errors in hospitalized adults who died or were transferred to intensive care. Auerbach AD, Lee TM, Hubbard CC, et al for the UPSIDE Research Group. JAMA Inte…
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psnet.ahrq.gov/issue/evidence-based-organization-and-patient-safety-strategies-european-hospitals
January 20, 2016 - Study
Evidence-based organization and patient safety strategies in European hospitals.
Citation Text:
Suñol R, Wagner C, Arah OA, et al. Evidence-based organization and patient safety strategies in European hospitals. Int J Qual Health Care. 2014;26 Suppl 1:47-55. doi:10.1093/intqhc/mzu0…
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psnet.ahrq.gov/issue/opennotes-and-patient-safety-perilous-voyage-uncharted-waters
March 10, 2021 - Commentary
OpenNotes and patient safety: a perilous voyage into uncharted waters.
Citation Text:
Schust G, Manning M, Weil A. OpenNotes and patient safety: a perilous voyage into uncharted waters. J Gen Intern Med. 2022;37(8):2074-2076. doi:10.1007/s11606-021-07384-2.
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psnet.ahrq.gov/issue/trial-and-error-learning-malpractice-claims-childhood-surgery
March 09, 2022 - Study
Trial and error: learning from malpractice claims in childhood surgery.
Citation Text:
Prieto JM, Falcone B, Greenberg P, et al. Trial and error: learning from malpractice claims in childhood surgery. J Surg Res. 2022;279:84-88. doi:10.1016/j.jss.2022.05.033.
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psnet.ahrq.gov/issue/bridging-gap-framework-and-strategies-integrating-quality-and-safety-mission-teaching
April 24, 2018 - Commentary
Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.
Citation Text:
Tess A, Vidyarthi A, Yang J, et al. Bridging the Gap: A Framework and Strategies for Integrating the Quality and Saf…
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psnet.ahrq.gov/issue/untenable-expectations-nurses-work-context-medication-administration-error-and-organization
September 21, 2022 - Study
Untenable expectations: nurses' work in the context of medication administration, error, and the organization.
Citation Text:
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration, error, and the organization. Glob Qual Nurs Res. 202…
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psnet.ahrq.gov/issue/automated-dispensing-cabinet-overrides-evaluation-necessity-pediatric-emergency-department
October 21, 2020 - Study
Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.
Citation Text:
Paterson EP, Manning KB, Schmidt MD, et al. Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department. J Emerg Nurs. 202…
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psnet.ahrq.gov/issue/diagnostic-blood-loss-phlebotomy-and-hospital-acquired-anemia-during-acute-myocardial
March 14, 2022 - Study
Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.
Citation Text:
Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…
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psnet.ahrq.gov/issue/emergency-department-checklist-innovation-improve-safety-emergency-care
December 20, 2023 - Commentary
Emergency department checklist: an innovation to improve safety in emergency care.
Citation Text:
Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-00…
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psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
January 22, 2017 - Study
Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.
Citation Text:
Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…
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psnet.ahrq.gov/issue/framework-patient-safety-defense-nuclear-industry-based-high-reliability-model
June 14, 2017 - Commentary
A framework for patient safety: a defense nuclear industry-based high-reliability model.
Citation Text:
Birnbach DJ, Rosen LF, Williams L, et al. A framework for patient safety: a defense nuclear industry--based high-reliability model. Jt Comm J Qual Patient Saf. 2013;39(5):…
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psnet.ahrq.gov/issue/provider-and-pharmacist-responses-warfarin-drug-drug-interaction-alerts-study-healthcare
July 29, 2020 - Study
Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.
Citation Text:
Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…
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psnet.ahrq.gov/issue/sbar-mm-feasible-reliable-and-valid-tool-assess-quality-surgical-morbidity-and-mortality
July 02, 2014 - Study
SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.
Citation Text:
Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and …
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psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting
July 13, 2009 - Commentary
Creating a just culture in the perioperative setting.
Citation Text:
Hooven K, Altmiller G. Creating a just culture in the perioperative setting. AORN J. 2024;119(2):152-160. doi:10.1002/aorn.14074.
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psnet.ahrq.gov/issue/physician-led-chart-audit-engaging-providers-fortifying-culture-safety
November 20, 2013 - Study
The "physician-led chart audit": engaging providers in fortifying a culture of safety.
Citation Text:
Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000…
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psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
May 13, 2009 - Commentary
Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.
Citation Text:
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…
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psnet.ahrq.gov/issue/barcode-medication-administration-software-technology-use-emergency-department-and-medication
November 04, 2015 - Study
Barcode medication administration software technology use in the emergency department and medication error rates.
Citation Text:
Gauthier-Wetzel HE. Barcode medication administration software technology use in the emergency department and medication error rates. Comput Inform Nurs.…