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www.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
October 01, 2014 - Project Overview: Designing Consumer Reporting Systems for Patient Safety Events
Current patient safety event reporting systems are aimed at obtaining information from health care providers. However, patients and their family members are in a unique position to identify gaps in care that may have co…
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psnet.ahrq.gov/issue/do-patient-safety-indicators-explain-increased-weekend-mortality
June 01, 2011 - Study
Do patient safety indicators explain increased weekend mortality?
Citation Text:
Ricciardi R, Nelson J, Francone TD, et al. Do patient safety indicators explain increased weekend mortality? J Surg Res. 2016;200(1):164-70. doi:10.1016/j.jss.2015.07.030.
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psnet.ahrq.gov/issue/medicare-letters-curb-overprescribing-controlled-substances-had-no-detectable-effect
May 25, 2016 - Study
Medicare letters to curb overprescribing of controlled substances had no detectable effect on providers.
Citation Text:
Sacarny A, Yokum D, Finkelstein A, et al. Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers. Health Aff (Mil…
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psnet.ahrq.gov/issue/impact-incorporating-pharmacy-claims-data-electronic-medication-reconciliation
September 01, 2016 - Study
Impact of incorporating pharmacy claims data into electronic medication reconciliation.
Citation Text:
Phansalkar S, Her QL, Tucker AD, et al. Impact of incorporating pharmacy claims data into electronic medication reconciliation. Am J Health Syst Pharm. 2015;72(3):212-7. doi:10.21…
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psnet.ahrq.gov/issue/potential-unintended-consequences-due-medicares-no-pay-errors-rule-randomized-controlled
July 02, 2014 - Study
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Citation Text:
Mookherjee S, Vidyarthi AR, Ranji SR, et al. Potential Unintended Consequences Due to Medica…
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psnet.ahrq.gov/issue/sustaining-gains-7-year-follow-through-hospital-wide-patient-safety-improvement-project
October 19, 2022 - Study
Sustaining the gains: a 7-year follow-through of a hospital-wide patient safety improvement project on hospital-wide adverse event outcomes and patient safety culture.
Citation Text:
Sim MA, Ti LK, Mujumdar S, et al. Sustaining the gains: a 7-year follow-through of a hospital-wide …
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psnet.ahrq.gov/issue/effects-2011-duty-hour-reforms-interns-and-their-patients-prospective-longitudinal-cohort
October 19, 2022 - Study
Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study.
Citation Text:
Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA In…
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psnet.ahrq.gov/issue/electronic-trigger-based-care-escalation-identify-preventable-adverse-events-hospitalised
September 28, 2016 - Study
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An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Citation Text:
Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable adverse even…
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psnet.ahrq.gov/issue/patient-voices-hospital-safety-during-covid-19-pandemic
March 17, 2021 - Study
Patient voices in hospital safety during the COVID-19 pandemic.
Citation Text:
Groves PS, Bunch JL, Hanrahan KM, et al. Patient voices in hospital safety during the COVID-19 pandemic. Clin Nurs Res. 2023;32(1):105-114. doi:10.1177/10547738221129711.
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psnet.ahrq.gov/issue/missed-acute-coronary-syndrome-during-telephone-triage-out-hours-primary-care-lessons-case
March 11, 2020 - Study
Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.
Citation Text:
Erkelens DC, Rutten FH, Wouters LT, et al. Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care. J Patient Saf. 2022…
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psnet.ahrq.gov/issue/learning-errors-analysis-medication-order-voiding-cpoe-systems
May 29, 2019 - Study
Learning from errors: analysis of medication order voiding in CPOE systems.
Citation Text:
Kannampallil TG, Abraham J, Solotskaya A, et al. Learning from errors: analysis of medication order voiding in CPOE systems. J Am Med Inform Assoc. 2017;24(4):762-768. doi:10.1093/jamia/ocw18…
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psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient
June 01, 2016 - Study
Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis.
Citation Text:
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factor…
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psnet.ahrq.gov/issue/workplace-violence-pervasiveness-perioperative-environment-multiprofessional-survey
November 11, 2020 - Study
Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey.
Citation Text:
Lin DM, Lane-Fall MB, Lea JA, et al. Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. Jt Comm J Qual Patient Saf. 2024;50(11):…
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psnet.ahrq.gov/issue/sign-out-snapshot-cross-sectional-evaluation-written-sign-outs-among-specialties
November 20, 2013 - Study
Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties.
Citation Text:
Schoenfeld AR, Al-Damluji MS, Horwitz LI. Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties. BMJ Qual Saf. 2014;23(1):66-72. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/issue/user-testing-guidelines-improve-safety-intravenous-medicines-administration-randomised-situ
November 16, 2022 - Study
User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.
Citation Text:
Jones MD, McGrogan A, Raynor DK, et al. User-testing guidelines to improve the safety of intravenous medicines administration: a randomised i…
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psnet.ahrq.gov/issue/patient-handovers-within-hospital-translating-knowledge-motor-racing-healthcare
April 01, 2015 - Study
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Patient handovers within the hospital: translating knowledge from motor racing to healthcare.
Citation Text:
Catchpole K, Sellers R, Goldman A, et al. Patient handovers within the hospital: translating knowledge from motor racing to healthcare. Q…
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psnet.ahrq.gov/issue/patient-education-prevent-falls-among-older-hospital-inpatients-randomized-controlled-trial
February 14, 2017 - Study
Patient education to prevent falls among older hospital inpatients: a randomized controlled trial.
Citation Text:
Haines TP, Hill A-M, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Arch Intern Med. 2011;171(6):516…
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psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses
March 28, 2012 - Study
Classic
Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.
Citation Text:
Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Cancer. 2005;104(10):2205-13.…
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psnet.ahrq.gov/issue/safety-culture-cardiac-surgical-teams-data-five-programs-and-national-surgical-comparison
May 24, 2012 - Study
Safety culture in cardiac surgical teams: data from five programs and national surgical comparison.
Citation Text:
Marsteller JA, Wen M, Hsu Y-J, et al. Safety Culture in Cardiac Surgical Teams: Data From Five Programs and National Surgical Comparison. Ann Thorac Surg. 2015;100(6):…
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psnet.ahrq.gov/issue/impact-electronic-health-record-alert-inappropriate-prescribing-high-risk-medications
August 25, 2021 - Study
Impact of an electronic health record alert on inappropriate prescribing of high-risk medications to patients with concurrent "do not give" orders.
Citation Text:
Smith K, Durant KM, Zimmerman C. Impact of an electronic health record alert on inappropriate prescribing of high-risk …