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psnet.ahrq.gov/issue/central-venous-catheter-guidewire-retention-lessons-englands-never-event-database
September 15, 2021 - Study
Central venous catheter guidewire retention: lessons from England's never event database.
Citation Text:
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10…
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psnet.ahrq.gov/issue/understanding-multidimensional-effects-resident-duty-hours-restrictions-thematic-analysis
July 03, 2016 - Review
Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery.
Citation Text:
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Anal…
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psnet.ahrq.gov/issue/frequency-missed-test-results-and-associated-treatment-delays-highly-computerized-health
July 22, 2009 - Study
The frequency of missed test results and associated treatment delays in a highly computerized health system.
Citation Text:
Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC Fam Pract. 2007;8:32.
…
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psnet.ahrq.gov/issue/using-four-phased-unit-based-patient-safety-walkrounds-uncover-correctable-system-flaws
October 05, 2022 - Study
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.
Citation Text:
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…
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psnet.ahrq.gov/issue/mhealth-design-promote-medication-safety-children-medical-complexity
July 14, 2010 - Study
An mHealth design to promote medication safety in children with medical complexity.
Citation Text:
Jolliff A, Coller RJ, Kearney H, et al. An mHealth design to promote medication safety in children with medical complexity. Appl Clin Inform. 2024;15(1):45-54. doi:10.1055/a-2214-8000…
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psnet.ahrq.gov/issue/mandatory-provider-review-and-pain-clinic-laws-reduce-amounts-opioids-prescribed-and-overdose
August 02, 2017 - Study
Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.
Citation Text:
Dowell D, Zhang K, Noonan RK, et al. Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates. He…
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psnet.ahrq.gov/issue/interns-compliance-accreditation-council-graduate-medical-education-work-hour-limits
January 07, 2011 - Study
Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits.
Citation Text:
Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006;296(9):1063-70.
Cop…
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psnet.ahrq.gov/issue/factors-influencing-nurses-decision-question-medication-administration-neonatal-clinical-care
April 21, 2021 - Study
Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.
Citation Text:
Aydon L, Hauck Y, Zimmer M, et al. Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit. J Clin Nur…
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psnet.ahrq.gov/issue/residents-response-duty-hour-regulations-follow-national-survey
December 02, 2014 - Study
Classic
Residents' response to duty-hour regulations—a follow-up national survey.
Citation Text:
Drolet BC, Christopher DA, Fischer SA. Residents' response to duty-hour regulations--a follow-up national survey. N Engl J Med. 2012;366(24):e35. doi:10.1056…
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psnet.ahrq.gov/issue/inpatient-safety-outcomes-following-2011-residency-work-hour-reform
September 04, 2013 - Study
Inpatient safety outcomes following the 2011 residency work-hour reform.
Citation Text:
Block L, Jarlenski M, Wu AW, et al. Inpatient safety outcomes following the 2011 residency work-hour reform. J Hosp Med. 2014;9(6). doi:10.1002/jhm.2171.
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DOI …
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psnet.ahrq.gov/issue/effectiveness-written-hospitalist-sign-outs-answering-overnight-inquiries
January 15, 2014 - Study
Effectiveness of written hospitalist sign-outs in answering overnight inquiries.
Citation Text:
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. Effectiveness of written hospitalist sign-outs in answering overnight inquiries. J Hosp Med. 2013;8(11):609-14. doi:10.1002/jhm.2090.
C…
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psnet.ahrq.gov/issue/monitoring-harm-associated-use-anticoagulants-pediatric-populations-through-trigger-based
November 11, 2015 - Study
Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection.
Citation Text:
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in pediatric populations t…
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psnet.ahrq.gov/issue/developing-and-evaluating-automated-all-cause-harm-trigger-system
July 31, 2013 - Study
Developing and evaluating an automated all-cause harm trigger system.
Citation Text:
Sammer C, Miller S, Jones C, et al. Developing and Evaluating an Automated All-Cause Harm Trigger System. Jt Comm J Qual Patient Saf. 2017;43(4):155-165. doi:10.1016/j.jcjq.2017.01.004.
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psnet.ahrq.gov/issue/association-overlapping-surgery-increased-risk-complications-following-hip-surgery
November 21, 2021 - Study
Classic
Association of overlapping surgery with increased risk for complications following hip surgery.
Citation Text:
Ravi B, Pincus D, Wasserstein D, et al. Association of Overlapping Surgery With Increased Risk for Complications Following Hip Surgery: A…
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www.ahrq.gov/es/tools/index.html?page=0
December 01, 2015 - Comprehensive Unit-based Safety Program (CUSP) The CUSP toolkit includes training tools to make care safer. More
The SHARE Approach Five-step process for clinicians and their patients More
EvidenceNOW Tools for Change Helping practices implement evidence More
Tools
The …
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psnet.ahrq.gov/issue/are-surgeons-and-anesthesiologists-lying-each-other-or-gaming-system-national-random-sample
June 29, 2022 - Study
Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States.
Citation Text:
Nurok M, Lee Y-Y, Ma Y, et al. Are surgeons and anesthesiologists lying to …
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psnet.ahrq.gov/issue/identifying-hospitalized-patients-risk-harm-comparison-nurse-perceptions-vs-electronic-risk
November 03, 2015 - Study
Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores.
Citation Text:
Stafos A, Stark S, Barbay K, et al. CE: Original Research: Identifying Hospitalized Patients at Risk for Harm: A Comparison of Nurse Perc…
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psnet.ahrq.gov/issue/development-and-preliminary-testing-coordination-process-error-reporting-tool-cpert
May 25, 2016 - Study
Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.
Citation Text:
Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the…
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www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
August 01, 2022 - AHRQ Views: Blog posts from AHRQ leaders
AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors
AUG
22
2022
By
Robert Otto
Valdez,
Ph.D., M.H.S.A.
R. Valdez, Ph.D., M.H.S.A.
Too many Americans have experienced the health-related consequences and anxieties that f…
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psnet.ahrq.gov/issue/exploring-health-care-professionals-perceptions-incidents-and-incident-reporting
August 28, 2013 - Study
Exploring health care professionals' perceptions of incidents and incident reporting in rehabilitation settings.
Citation Text:
Espin S, Carter C, Janes N, et al. Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings. J Pati…