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psnet.ahrq.gov/issue/laboratory-session-improve-first-year-pharmacy-students-knowledge-and-confidence-concerning
September 08, 2021 - Study
Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.
Citation Text:
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students' knowledge and confidence conce…
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psnet.ahrq.gov/issue/they-say-they-listen-do-they-really-listen-qualitative-study-hospital-doctors-experiences
November 29, 2017 - Study
"They say they listen. But do they really listen?": A qualitative study of hospital doctors' experiences of organisational deafness, disconnect and denial.
Citation Text:
Creese J, Byrne JP, Conway E, et al. “They say they listen. But do they really listen?”: A qualitative study of…
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psnet.ahrq.gov/issue/crew-resource-management-improved-perception-patient-safety-operating-room
April 27, 2010 - Study
Crew resource management improved perception of patient safety in the operating room.
Citation Text:
Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of patient safety in the operating room. Am J Med Qual. 2010;25(1):60-3. doi:10.1177/1062860609351…
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psnet.ahrq.gov/issue/field-test-world-health-organization-multi-professional-patient-safety-curriculum-guide
June 04, 2014 - Study
Field test of the World Health Organization Multi-professional Patient Safety Curriculum Guide.
Citation Text:
Farley DO, Zheng H, Rousi E, et al. Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide. PLoS One. 2015;10(9):e0138510. doi:10.1…
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psnet.ahrq.gov/issue/predicting-potential-postdischarge-adverse-drug-events-and-30-day-unplanned-hospital
December 09, 2009 - Study
Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity.
Citation Text:
Schoonover H, Corbett CF, Weeks DL, et al. Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readm…
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psnet.ahrq.gov/issue/patient-safety-factors-and-perceived-consequences-nursing-errors-nursing-staff-home-care
May 18, 2022 - Study
Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services.
Citation Text:
Jachan DE, Müller‐Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. N…
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psnet.ahrq.gov/issue/wrong-site-nerve-blocks-10-yr-experience-large-multihospital-health-care-system
January 14, 2011 - Study
Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.
Citation Text:
Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system. Br J Anaesth. 2015;114(5):818-24. doi:10.1093/bja/aeu490.
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psnet.ahrq.gov/issue/disparities-patient-safety-voluntary-event-reporting-scoping-review
November 16, 2022 - Review
Disparities in patient safety voluntary event reporting: a scoping review.
Citation Text:
Hoops K, Pittman E, Stockwell DC. Disparities in patient safety voluntary event reporting: a scoping review. Jt Comm J Qual Patient Saf. 2024;50(1):41-48. doi:10.1016/j.jcjq.2023.10.009.
Co…
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psnet.ahrq.gov/issue/adverse-events-patients-return-emergency-department-visits
May 31, 2017 - Study
Adverse events in patients with return emergency department visits.
Citation Text:
Calder LA, Pozgay A, Riff S, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142-148. doi:10.1136/bmjqs-2014-003194.
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psnet.ahrq.gov/issue/frequency-and-risk-factors-medication-errors-pharmacists-during-order-verification-tertiary
January 23, 2013 - Study
Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center.
Citation Text:
Gorbach C, Blanton L, Lukawski BA, et al. Frequency of and risk factors for medication errors by pharmacists during order verification in a…
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psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
January 19, 2022 - Study
Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.
Citation Text:
Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive c…
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psnet.ahrq.gov/issue/cracking-code-quality-interrelationships-culture-nurse-demographics-advocacy-and-patient
December 01, 2011 - Study
Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.
Citation Text:
DiCuccio MH, Colbert AM, Triolo PK, et al. Cracking the Code for Quality. J Nurs Admin. 2020;50(3):152-158. doi:10.1097/nna.0000000000000859.
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psnet.ahrq.gov/issue/use-colour-coded-labels-intravenous-high-risk-medications-and-lines-improve-patient-safety
December 29, 2014 - Study
Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety.
Citation Text:
Porat N, Bitan Y, Shefi D, et al. Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. Qual Saf Health Care. 2009;…
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www.ahrq.gov/teamstepps-program/evidence-base/intensive.html
June 01, 2023 - TeamSTEPPS Research/Evidence Base: Intensive Care
Anderson RJ, Sparbel K, Barr RN, Doerschug K, Corbridge S. Electronic health record tool to promote team communication and early patient mobility in the intensive care unit. Crit Care Nurse . 2018;38(6):23-34. Epub 2018/12/07. doi: 10.4037/ccn2018813. PMID: 305…
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psnet.ahrq.gov/issue/epidemiology-malpractice-claims-primary-care-systematic-review
June 13, 2011 - Review
The epidemiology of malpractice claims in primary care: a systematic review.
Citation Text:
Wallace E, Lowry J, Smith SM, et al. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open. 2013;3(7). doi:10.1136/bmjopen-2013-002929.
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psnet.ahrq.gov/issue/measuring-administrators-and-direct-care-workers-perceptions-safety-culture-assisted-living
June 02, 2010 - Study
Measuring administrators' and direct care workers' perceptions of the safety culture in assisted living facilities.
Citation Text:
Castle NG, Wagner LM, Sonon K, et al. Measuring administrators' and direct care workers' perceptions of the safety culture in assisted living facilitie…
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psnet.ahrq.gov/issue/perceptual-gaps-between-clinicians-and-technologists-health-information-technology-related
March 11, 2020 - Study
Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study.
Citation Text:
Ndabu T, Mulgund P, Sharman R, et al. Perceptual gaps between clinicians and technologists on health information technology-related…
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psnet.ahrq.gov/issue/human-error-not-communication-and-systems-underlies-surgical-complications
November 18, 2020 - Study
Human error, not communication and systems, underlies surgical complications.
Citation Text:
Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impmenu.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential
ways facility teams may choose to integrate the pressure ulcer healing reports into clinical
practice. A menu of…
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psnet.ahrq.gov/issue/improving-governance-patient-safety-emergency-care-systematic-review-interventions
March 06, 2013 - Review
Improving the governance of patient safety in emergency care: a systematic review of interventions.
Citation Text:
Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837…