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psnet.ahrq.gov/issue/safety-culture-transformation-its-effects-childrens-hospital
November 04, 2014 - Study
A safety culture transformation: its effects at a children's hospital.
Citation Text:
Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children's hospital. J Patient Saf. 2012;8(3):125-30. doi:10.1097/PTS.0b013e31824bd744.
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psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model
June 29, 2009 - Commentary
Using incident reporting to improve patient safety: a conceptual model.
Citation Text:
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
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psnet.ahrq.gov/issue/commissioning-simulations-test-new-healthcare-facilities-proactive-and-innovative-approach
September 30, 2020 - Commentary
Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.
Citation Text:
Kaba A, Barnes S. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system …
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psnet.ahrq.gov/issue/ashp-guidelines-preventing-diversion-controlled-substances
June 15, 2022 - Organizational Policy/Guidelines
ASHP Guidelines on Preventing Diversion of Controlled Substances.
Citation Text:
Clark J, Fera T, Fortier CR, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246.…
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psnet.ahrq.gov/issue/optimizing-situation-awareness-reduce-emergency-transfers-hospitalized-children
January 19, 2022 - Study
Optimizing situation awareness to reduce emergency transfers in hospitalized children.
Citation Text:
Sosa T, Sitterding M, Dewan M, et al. Optimizing situation awareness to reduce emergency transfers in hospitalized children. Pediatrics. 2021;148(4):e2020034603. doi:10.1542/peds.2…
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psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation
June 18, 2013 - Commentary
A case of the birth and death of a high reliability healthcare organisation.
Citation Text:
Roberts KH, Madsen P, Desai V, et al. A case of the birth and death of a high reliability healthcare organisation. Qual Saf Health Care. 2005;14(3):216-20.
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psnet.ahrq.gov/issue/patterns-unexpected-hospital-deaths-root-cause-analysis
March 13, 2019 - Review
Patterns of unexpected in-hospital deaths: a root cause analysis.
Citation Text:
Lynn LA, Curry P. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg. 2011;5(1):3. doi:10.1186/1754-9493-5-3.
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psnet.ahrq.gov/issue/composite-measures-profiling-hospitals-bariatric-surgery-performance
January 31, 2013 - Study
Composite measures for profiling hospitals on bariatric surgery performance.
Citation Text:
Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg. 2014;149(1):10-6. doi:10.1001/jamasurg.2013.4109.
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psnet.ahrq.gov/issue/multiple-interacting-factors-influence-adherence-and-outcomes-associated-surgical-safety
June 21, 2016 - Study
Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study.
Citation Text:
Gagliardi AR, Straus SE, Shojania KG, et al. Multiple interacting factors influence adherence, and outcomes associated with surgical safety…
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psnet.ahrq.gov/issue/managing-discontinuity-academic-medical-centers-strategies-safe-and-effective-resident-sign
November 26, 2014 - Review
Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
Citation Text:
Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. J Hosp…
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psnet.ahrq.gov/issue/situ-simulation-detection-safety-threats-and-teamwork-training-high-risk-emergency-department
May 23, 2013 - Study
In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.
Citation Text:
Patterson M, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf…
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psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative
February 03, 2011 - Study
Stopping the error cascade: a report on ameliorators from the ASIPS collaborative.
Citation Text:
Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care. 2007;16(1):12-6.
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psnet.ahrq.gov/issue/beam-me-scotty-impact-personal-wireless-communication-devices-emergency-department
July 17, 2013 - Study
Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.
Citation Text:
Richards JD, Harris T. Beam me up Scotty! Impact of personal wireless communication devices in the emergency department. Emerg Med J. 2011;28(1):29-32. doi:10.1136/emj…
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psnet.ahrq.gov/issue/implicit-racial-bias-pediatric-orthopaedic-surgery
September 21, 2022 - Study
Implicit racial bias in pediatric orthopaedic surgery.
Citation Text:
Guzek R, Goodbody CM, Jia L, et al. Implicit racial bias in pediatric orthopaedic surgery. J Pediatr Orthop. 2022;42(7):393-399. doi:10.1097/bpo.0000000000002170.
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psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event
September 21, 2022 - Commentary
Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".
Citation Text:
Barth RJ, Waljee JF. Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". JAMA Surg. 2020;155(7):543-544. doi:10.…
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psnet.ahrq.gov/issue/implementation-bar-code-medication-administration-reduce-patient-harm
September 23, 2020 - Study
Implementation of bar-code medication administration to reduce patient harm.
Citation Text:
Thompson KM, Swanson KM, Cox DL, et al. Implementation of Bar-Code Medication Administration to Reduce Patient Harm. Mayo Clin Proc Innov Qual Outcomes. 2018;2(4):342-351. doi:10.1016/j.mayo…
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psnet.ahrq.gov/issue/misuse-pediatric-medications-and-parent-physician-communication-interactive-voice-response
May 27, 2011 - Study
Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention.
Citation Text:
Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention. J Pa…
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psnet.ahrq.gov/issue/common-patterns-558-diagnostic-radiology-errors
July 19, 2023 - Study
Common patterns in 558 diagnostic radiology errors.
Citation Text:
Donald JJ, Barnard SA. Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol. 2012;56(2):173-178. doi:10.1111/j.1754-9485.2012.02348.x.
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psnet.ahrq.gov/issue/clinical-handover-critically-ill-postoperative-patient-integrative-review
March 23, 2016 - Review
Clinical handover of the critically ill postoperative patient: an integrative review.
Citation Text:
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.…
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psnet.ahrq.gov/issue/effectiveness-interventions-improve-patient-handover-surgery-systematic-review
June 25, 2018 - Review
Effectiveness of interventions to improve patient handover in surgery: a systematic review.
Citation Text:
Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in surgery: A systematic review. Surgery. 2015;158(1):85-95. doi:10.1016…