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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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psnet.ahrq.gov/issue/how-intervention-studies-measure-effectiveness-medication-safety-related-clinical-decision
December 14, 2022 - Review
How intervention studies measure the effectiveness of medication safety-related clinical decision support systems in primary and long-term care: a systematic review.
Citation Text:
Lampe D, Grosser J, Grothe D, et al. How intervention studies measure the effectiveness of medicatio…
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psnet.ahrq.gov/issue/improving-healthcare-systems-disclosures-large-scale-adverse-events-department-veterans
August 18, 2021 - Study
Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.
Citation Text:
Elwy R, Bokhour BG, Maguire EM, et al. Improving healthcare systems' disclosures of large-scale ad…
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psnet.ahrq.gov/issue/human-based-errors-involving-smart-infusion-pumps-catalog-error-types-and-prevention
November 16, 2022 - Review
Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.
Citation Text:
Kirkendall ES, Timmons K, Huth H, et al. Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies. Drug Saf. 2020;43(1…
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psnet.ahrq.gov/issue/development-and-applications-veterans-health-administrations-stratification-tool-opioid-risk
April 01, 2020 - Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Citation Text:
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans He…
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psnet.ahrq.gov/issue/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Study
A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.
Citation Text:
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care p…
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psnet.ahrq.gov/issue/use-electronic-clinical-decision-support-system-primary-care-assess-inappropriate
October 21, 2020 - Study
Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study
Citation Text:
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an ele…
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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/issue/exploring-roots-unintended-safety-threats-associated-introduction-hospital-eprescribing
December 21, 2022 - Study
Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.
Citation Text:
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended…
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psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
May 18, 2022 - Study
Patient safety and telephone medicine: some lessons from closed claim case review.
Citation Text:
Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…
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psnet.ahrq.gov/issue/safety-electronic-prescribing-manifestations-mechanisms-and-rates-system-related-errors
February 15, 2012 - Study
The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals.
Citation Text:
Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and rates…
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psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
May 01, 2015 - Book/Report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Citation Text:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/what-stops-hospital-clinical-staff-following-protocols-analysis-incidence-and-factors-behind
September 09, 2015 - Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Citation Text:
Shearer B, Marshal…
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.