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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - An implementation strategy for a multicenter pediatric
rapid response system in Ontario.
January 3, 2017
Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for
Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6).
doi:10.1016/s1553…
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psnet.ahrq.gov/node/837763/psn-pdf
August 03, 2022 - Implementation of hand hygiene in health-care facilities:
results from the WHO Hand Hygiene Self-Assessment
Framework global survey 2019.
August 3, 2022
de Kraker MEA, Tartari E, Tomczyk S, et al. Implementation of hand hygiene in health-care facilities:
results from the WHO Hand Hygiene Self-Assessment Framework …
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psnet.ahrq.gov/node/74267/psn-pdf
January 19, 2022 - Support opportunities for second victims lessons
learned: a qualitative study of the top 20 US News and
World Report Honor Roll Hospitals.
January 19, 2022
Marr R, Goyal A, Quinn M, et al. Support opportunities for second victims lessons learned: a qualitative
study of the top 20 US News and World Report Honor Rol…
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psnet.ahrq.gov/node/866554/psn-pdf
August 21, 2024 - Multi-team shared expectations tool (MT-SET): an
exercise to improve teamwork across health care teams.
August 21, 2024
Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to
improve teamwork across health care teams. Jt Comm J Qual Patient Saf. 2024;50(10):737-744.
…
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psnet.ahrq.gov/node/764402/psn-pdf
March 02, 2022 - A systematic review of methods for medical record
analysis to detect adverse events in hospitalized patients.
March 2, 2022
Klein DO, Rennenberg RJMW, Koopmans RP, et al. A systematic review of methods for medical record
analysis to detect adverse events in hospitalized patients. J Patient Saf. 2021;17(8):e1234-e12…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…
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psnet.ahrq.gov/node/867013/psn-pdf
October 23, 2024 - Reducing automated dispensing cabinet overrides in the
peri-anesthesia care unit: a quality improvement project.
October 23, 2024
Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri-
anesthesia care unit: a quality improvement project. Jt Comm J Qual Patient Saf. …
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psnet.ahrq.gov/node/60591/psn-pdf
June 17, 2020 - National trends in the safety performance of electronic
health record systems from 2009 to 2018.
June 17, 2020
Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record
systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547.
htt…
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psnet.ahrq.gov/node/38891/psn-pdf
January 04, 2010 - Do calculation errors by nurses cause medication errors
in clinical practice? A literature review.
January 4, 2010
Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review.
Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2009.06.009.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/38759/psn-pdf
April 05, 2010 - Perceptions of the impact of a large-scale collaborative
improvement programme: experience in the UK Safer
Patients Initiative.
April 5, 2010
Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement
programme: experience in the UK Safer Patients Initiative. J Eval Cl…
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psnet.ahrq.gov/node/41777/psn-pdf
April 05, 2013 - Effect of nonpayment for preventable infections in U.S.
hospitals.
April 5, 2013
Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals.
N Engl J Med. 2012;367(15):1428-37. doi:10.1056/NEJMsa1202419.
https://psnet.ahrq.gov/issue/effect-nonpayment-preventable-infec…
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psnet.ahrq.gov/node/44965/psn-pdf
February 15, 2017 - Identification and Prioritization of Health IT Patient Safety
Measures.
February 15, 2017
Washington, DC: National Quality Forum; February 2016.
https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
Health information technology (IT) has transformed health care and improv…
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psnet.ahrq.gov/node/839314/psn-pdf
November 02, 2022 - Correlation between the number of patient-reported
adverse events, adverse drug events, and quality of life in
older patients: an observational study.
November 2, 2022
Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Correlation between the number of patient-
reported adverse events, adverse drug events, and…
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psnet.ahrq.gov/node/38964/psn-pdf
November 27, 2009 - Development of a measure of patient safety event
learning responses.
November 27, 2009
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning
responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
https://psnet.ahrq.gov/issue/development-…
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psnet.ahrq.gov/node/37510/psn-pdf
March 04, 2011 - Rare adverse medical events in VA inpatient care:
reliability limits to using patient safety indicators as
performance measures.
March 4, 2011
West AN, Weeks WB, Bagian JP. Rare adverse medical events in VA inpatient care: reliability limits to
using patient safety indicators as performance measures. Health Serv R…
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - While only a few studies reviewed
implementation in a clinical setting (most evaluated algorithm technical
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - through a certification process where providers can be assessed while taking a BPMH and their skills evaluated
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psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - He was re-
evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - She paged the on-call
team who immediately evaluated the patient and successfully treated him for symptomatic
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Providers should document each step in the PN-use process so that any errors can be evaluated
and corrective