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psnet.ahrq.gov/issue/clinicians-satisfaction-cpoe-ease-use-and-effect-clinicians-workflow-efficiency-and
August 10, 2022 - Study
Clinicians' satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety.
Citation Text:
Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medicatio…
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psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety
March 13, 2013 - Commentary
Classic
Balancing "no blame" with accountability in patient safety.
Citation Text:
Wachter R, Pronovost P. Balancing "no blame" with accountability in patient safety. New Engl J Med. 2009;361(14):1401-1406. doi:10.1056/NEJMsb0903885.
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psnet.ahrq.gov/issue/responding-clinicians-who-fail-follow-patient-safety-practices-perceptions-physicians-nurses
February 24, 2011 - Study
Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients.
Citation Text:
Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nu…
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psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence
March 01, 2011 - Study
High reliability in a safety net hospital leading to operational excellence.
Citation Text:
Didion L, Whitfield C, Bishop P, et al. High reliability in a safety net hospital leading to operational excellence. J Patient Saf. 2024;20(5):375-380. doi:10.1097/pts.0000000000001236.
Co…
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psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
February 02, 2022 - Review
The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.
Citation Text:
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…
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psnet.ahrq.gov/issue/implicit-bias-patient-descriptor-homeless-and-its-association-emergency-department-opioid
December 15, 2021 - Study
Implicit bias in the patient descriptor "homeless" and its association with emergency department opioid administration and disposition.
Citation Text:
Lauricella M, Nene RV, Coyne CJ, et al. Implicit bias in the patient descriptor “homeless” and its association with emergency depar…
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psnet.ahrq.gov/issue/evaluation-patient-and-family-outpatient-complaints-strategy-prioritize-efforts-improve
November 16, 2022 - Study
Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery.
Citation Text:
Mack JW, Jacobson J, Frank D, et al. Evaluation of Patient and Family Outpatient Complaints as a Strategy to Prioritize Efforts to Improve Canc…
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psnet.ahrq.gov/issue/attending-emotional-well-being-health-care-workforce-new-york-city-health-system-during-covid
December 23, 2020 - Commentary
Emerging Classic
Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic.
Citation Text:
Ripp JA, Peccoralo L, Charney D. Attending to the emotional well-being of the health care…
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psnet.ahrq.gov/issue/return-investment-vendor-computerized-physician-order-entry-four-community-hospitals
November 26, 2014 - Study
Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support.
Citation Text:
Zimlichman E, Keohane C, Franz C, et al. Return on investment for vendor computerized physician order entry in four community hospita…
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psnet.ahrq.gov/issue/changes-medical-errors-after-implementation-handoff-program
April 24, 2018 - Study
Classic
Changes in medical errors after implementation of a handoff program.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803-1812. doi:10.105…
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psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors
April 12, 2017 - Study
Automated detection of wrong-drug prescribing errors.
Citation Text:
Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf. 2019;28(11):908-915. doi:10.1136/bmjqs-2019-009420.
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Format:
DOI Google Scholar…
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psnet.ahrq.gov/issue/ambulatory-virtual-care-during-pandemic-patient-safety-considerations
August 12, 2020 - Study
Ambulatory virtual care during a pandemic: patient safety considerations.
Citation Text:
Mullur J, Chen Y-C, Wickner PG, et al. Ambulatory virtual care during a pandemic: patient safety considerations. J Patient Saf. 2022;18(2):e431-e438. doi:10.1097/pts.0000000000000832.
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psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient-safety-transformation
February 12, 2020 - Study
Lessons learned from a systems approach to engaging patients and families in patient safety transformation.
Citation Text:
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation. Jt Comm J Qua…
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Our contributions to date include summarizing existing information sources (e.g., case reports), establishing
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - reforming the private insurance market. 1 The ACA specifically sought to improve patient safety by establishing
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - reforming the private insurance market. 1 The ACA specifically sought to improve patient safety by establishing
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…