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psnet.ahrq.gov/node/44229/psn-pdf
October 13, 2015 - Patterns and predictors of medication discrepancies in
primary care.
October 13, 2015
Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary
care. J Eval Clin Pract. 2015;21(5):831-9. doi:10.1111/jep.12387.
https://psnet.ahrq.gov/issue/patterns-and-predictors-medi…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - They keep looking at the issues and they
keep evaluating what's going right and what's going wrong,
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psnet.ahrq.gov/node/867451/psn-pdf
January 21, 2025 - Engineering Safety into Practice through Implementation
of the EHR SAFER Guides.
January 8, 2025
National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through
Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern).
https://psnet.ahrq.gov/issue/engi…
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psnet.ahrq.gov/node/73613/psn-pdf
August 18, 2021 - Implementing universal suicide risk screening in a
pediatric hospital.
August 18, 2021
Sullivant SA, Brookstein D, Camerer M, et al. Implementing universal suicide risk screening in a pediatric
hospital. Jt Comm J Qual Patient Saf. 2021;47(8):496-502. doi:10.1016/j.jcjq.2021.05.001.
https://psnet.ahrq.gov/issue/im…
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psnet.ahrq.gov/node/34909/psn-pdf
February 27, 2009 - Decreasing clinically significant adverse events using
feedback to emergency physicians of telephone follow-up
outcomes.
February 27, 2009
Chern C-H, How C-K, Wang L-M, et al. Decreasing clinically significant adverse events using feedback to
emergency physicians of telephone follow-up outcomes. Ann Emerg Med. 200…
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psnet.ahrq.gov/node/47960/psn-pdf
May 15, 2019 - A systematic review of clinical decision support systems
for clinical oncology practice.
May 15, 2019
Pawloski PA, Brooks GA, Nielsen ME, et al. A Systematic Review of Clinical Decision Support Systems for
Clinical Oncology Practice. J Natl Compr Canc Netw. 2019;17(4):331-338. doi:10.6004/jnccn.2018.7104.
https://…
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psnet.ahrq.gov/node/37135/psn-pdf
October 04, 2011 - Combining ratings from multiple physician reviewers
helped to overcome the uncertainty associated with
adverse event classification.
October 4, 2011
Forster AJ, O'Rourke K, Shojania KG, et al. Combining ratings from multiple physician reviewers helped to
overcome the uncertainty associated with adverse event class…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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psnet.ahrq.gov/node/39838/psn-pdf
September 15, 2010 - A multicenter trial of aviation-style training for surgical
teams.
September 15, 2010
Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient
Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea.
https://psnet.ahrq.gov/issue/multicenter-trial-aviation-st…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/42660/psn-pdf
October 16, 2013 - Practice indicators of suboptimal care and avoidable
adverse events: a content analysis of a national qualifying
examination.
October 16, 2013
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse
events: a content analysis of a national qualifying examination. Acad…
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psnet.ahrq.gov/node/44057/psn-pdf
June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE
and practice and professional issues items.
June 3, 2015
Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and
professional issues items. J Nurs Manag. 2014;22(3):421-437.
https://psnet.ahrq.gov/issue/measuring-nursing-error-p…
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psnet.ahrq.gov/node/38904/psn-pdf
September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis
of claims against the NHS in England 1995-2007.
September 2, 2009
Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the
NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
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psnet.ahrq.gov/node/45970/psn-pdf
March 22, 2017 - A learning health care system using computer-aided
diagnosis.
March 22, 2017
Cahan A, Cimino JJ. A Learning Health Care System Using Computer-Aided Diagnosis. J Med Internet
Res. 2017;19(3):e54. doi:10.2196/jmir.6663.
https://psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis
Although…
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psnet.ahrq.gov/node/44227/psn-pdf
November 19, 2018 - A scholarly pathway in quality improvement and patient
safety.
November 19, 2018
Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med.
2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772.
https://psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety…
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psnet.ahrq.gov/node/50671/psn-pdf
November 20, 2019 - Critical errors in infrequently performed trauma
procedures after training.
November 20, 2019
Mackenzie CF, Shackelford SA, Tisherman SA, et al. Critical errors in infrequently performed trauma
procedures after training. Surgery. 2019;166(5):835-843. doi:10.1016/j.surg.2019.05.031.
https://psnet.ahrq.gov/issue/cri…
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psnet.ahrq.gov/node/74703/psn-pdf
January 26, 2022 - Research to improve diagnosis: time to study the real
world.
January 26, 2022
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf.
2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
Diagnostic …
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psnet.ahrq.gov/node/34646/psn-pdf
July 01, 2015 - The attributes of medical event reporting systems.
July 1, 2015
Battles JB, Kaplan HS, van der Schaaf TW, et al. The attributes of medical event-reporting systems:
experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med.
1998;122(3):231-8.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/839814/psn-pdf
January 01, 2023 - Influencing a culture of quality and safety through
huddles.
November 9, 2022
McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles.
J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642.
https://psnet.ahrq.gov/issue/influencing-culture-quality-a…
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psnet.ahrq.gov/node/37098/psn-pdf
October 04, 2011 - How residents think and make medical decisions:
implications for education and patient safety.
October 4, 2011
Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for
education and patient safety. Am Surg. 2007;73(6):548-553; discussion 553-4.
https://psnet.ahrq.gov/…