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psnet.ahrq.gov/issue/learning-preventable-adverse-events-health-care-organizations-development-multilevel-model
June 28, 2010 - Commentary
Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.
Citation Text:
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care organizations: development of a mu…
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psnet.ahrq.gov/issue/uptake-quality-related-event-standards-practice-community-pharmacies
November 09, 2016 - Study
Uptake of quality-related event standards of practice by community pharmacies.
Citation Text:
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
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psnet.ahrq.gov/issue/cognitive-debiasing-part-1-and-part-2
September 18, 2024 - Commentary
Cognitive debiasing; part 1 and part 2.
Citation Text:
Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64. doi:10.1136/bmjqs-2012-001712.
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psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-programmes-hospital-transitions-systematic-review-and
April 18, 2018 - Review
Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
Citation Text:
Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.…
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psnet.ahrq.gov/issue/developing-measure-value-health-care
February 10, 2021 - Commentary
Developing a measure of value in health care.
Citation Text:
Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health. 2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009.
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psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
November 11, 2020 - Commentary
Five strategies for a safer EHR modernization journey.
Citation Text:
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
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psnet.ahrq.gov/issue/effect-genetic-diagnosis-patients-previously-undiagnosed-disease
October 19, 2022 - Study
Effect of genetic diagnosis on patients with previously undiagnosed disease.
Citation Text:
Splinter K, Adams DR, Bacino CA, et al. Effect of Genetic Diagnosis on Patients with Previously Undiagnosed Disease. New Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458.
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psnet.ahrq.gov/issue/implementation-antibiotic-stewardship-program-long-term-care-facilities-across-us
July 20, 2022 - Study
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
Citation Text:
doi:http://www.doi.org/10.1001/jamanetworkopen.2022.0181.
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DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/high-reliability-organization-mindset
April 01, 2020 - Commentary
A high-reliability organization mindset.
Citation Text:
Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. doi:10.1097/jmq.0000000000000086.
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psnet.ahrq.gov/issue/5-year-analysis-rapid-response-system-activation-hospital-haemodialysis-unit
March 24, 2011 - Study
A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.
Citation Text:
Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:1…
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psnet.ahrq.gov/issue/patient-participation-patient-safety-and-nursing-input-systematic-review
June 10, 2020 - Review
Patient participation in patient safety and nursing input—a systematic review.
Citation Text:
Vaismoradi M, Jordan S, Kangasniemi M. Patient participation in patient safety and nursing input - a systematic review. J Clin Nurs. 2015;24(5-6):627-39. doi:10.1111/jocn.12664.
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psnet.ahrq.gov/issue/necessary-leadership-skillsets-high-reliability-organization-framework-adoption-within-acute
March 23, 2022 - Study
The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations.
Citation Text:
Logan‐Athmer AL. The necessary leadership skillsets for the high‐reliability organization framework adoption within acute healthcare org…
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psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-versus-draining-swamp
January 31, 2024 - Commentary
Root-cause analysis: swatting at mosquitoes versus draining the swamp.
Citation Text:
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
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psnet.ahrq.gov/issue/factors-affecting-patient-safety-culture-among-dental-healthcare-workers-nationwide-cross
June 16, 2021 - Study
Factors affecting patient safety culture among dental healthcare workers: A nationwide cross-sectional survey
Citation Text:
Cheng H-C, Yen AM-F, Lee Y-H. Factors affecting patient safety culture among dental healthcare workers: A nationwide cross-sectional survey. J Dent Sci. 2019…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
…
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and …
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…