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psnet.ahrq.gov/issue/clinical-evaluation-ade-scorecards-decision-support-tool-adverse-drug-event-analysis-and
December 31, 2014 - Study
Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safety management.
Citation Text:
Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug e…
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psnet.ahrq.gov/issue/managing-cognitive-biases-during-disaster-response-development-aide-memoire
November 16, 2022 - Review
Managing cognitive biases during disaster response: the development of an aide memoire.
Citation Text:
Brooks B, Curnin S, Owen C, et al. Managing cognitive biases during disaster response: the development of an aide memoire. Cogn Tech Work. 2020;22(2):249–261. doi:10.1007/s10111-…
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psnet.ahrq.gov/issue/nurses-perceptions-causes-medication-errors-and-barriers-reporting
March 21, 2018 - Study
Nurses' perceptions of causes of medication errors and barriers to reporting.
Citation Text:
Ulanimo VM, O'Leary-Kelley C, Connolly PM. Nurses' perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual. 2007;22(1):28-33.
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psnet.ahrq.gov/issue/cybersecurity-health-urgent-patient-safety-concern-we-can-learn-existing-patient-safety
October 28, 2020 - Commentary
Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it.
Citation Text:
O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn from existing pa…
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psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety
July 15, 2020 - Review
20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety.
Citation Text:
St.Pierre M, Grawe P, Bergström J, et al. 20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient …
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psnet.ahrq.gov/issue/engaging-patients-use-real-time-electronic-clinical-data-improve-safety-and-reliability-their
March 16, 2022 - Study
Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.
Citation Text:
Schnock KO, Roulier S, Butler J, et al. Engaging patients in the use of real-time electronic clinical data to improve the safety and reliabilit…
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www.ahrq.gov/news/newsroom/case-studies/201520.html
July 01, 2015 - Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS®
Search All Impact Case Studies
July 2015
Amery Hospital & Clinic, a 25-bed acute care critical access hospital in rural Wisconsin, used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site in…
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psnet.ahrq.gov/issue/cultural-transformation-after-implementation-crew-resource-management-it-really-possible
November 16, 2022 - Study
Cultural transformation after implementation of crew resource management: is it really possible?
Citation Text:
Hefner JL, Hilligoss B, Knupp A, et al. Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible? Am J Med Qual. 2017;32(4):384-390…
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psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe
October 05, 2022 - Study
Fast tracking in cardiac surgery: is it safe?
Citation Text:
MacLeod JB, D’Souza K, Aguiar C, et al. Fast tracking in cardiac surgery: is it safe? J Cardiothorac Surg. 2022;17(1):69. doi:10.1186/s13019-022-01815-9.
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psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
January 16, 2017 - Study
Classic
Adapting to new technologies in the operating room.
Citation Text:
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-613. doi:10.1518/001872096778827224.
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psnet.ahrq.gov/issue/accountability-medical-error-moving-beyond-blame-advocacy
December 19, 2018 - Review
Accountability for medical error: moving beyond blame to advocacy.
Citation Text:
Bell SK, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error: moving beyond blame to advocacy. Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533.
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psnet.ahrq.gov/issue/who-gets-benefit-doubt-performance-evaluations-medical-errors-and-production-gender
May 01, 2012 - Study
Who gets the benefit of the doubt? Performance evaluations, medical errors, and the production of gender inequality in emergency medical education.
Citation Text:
Brewer A, Osborne M, Mueller AS, et al. Who Gets the Benefit of the Doubt? Performance Evaluations, Medical Errors, an…
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psnet.ahrq.gov/issue/involvement-parents-critical-incidents-neonatal-paediatric-intensive-care-unit
January 22, 2016 - Study
Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.
Citation Text:
Frey B, Ersch J, Bernet V, et al. Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit. Qual Saf Health Care. 2009;18(6):446-9. doi:10.11…
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psnet.ahrq.gov/issue/impact-computerized-prescriber-order-entry-incidence-adverse-drug-events-pediatric-inpatients
October 19, 2022 - Study
Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.
Citation Text:
Holdsworth MT, Fichtl RE, Raisch DW, et al. Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.…
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psnet.ahrq.gov/issue/medication-report-reduces-number-medication-errors-when-elderly-patients-are-discharged
February 04, 2009 - Study
Medication report reduces number of medication errors when elderly patients are discharged from hospital.
Citation Text:
Midlöv P, Holmdahl L, Eriksson T, et al. Medication report reduces number of medication errors when elderly patients are discharged from hospital. Pharm World…
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psnet.ahrq.gov/issue/use-technology-urgent-clinician-clinician-communications-systematic-review-literature
September 09, 2015 - Review
The use of technology for urgent clinician to clinician communications: a systematic review of the literature.
Citation Text:
Nguyen C, McElroy LM, Abecassis MM, et al. The use of technology for urgent clinician to clinician communications: a systematic review of the literature. I…
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psnet.ahrq.gov/issue/excess-length-stay-charges-and-mortality-attributable-medical-injuries-during-hospitalization
February 27, 2009 - Study
Classic
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
Citation Text:
Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. …
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psnet.ahrq.gov/issue/learning-non-routine-events-and-teamwork-intensive-care-units-challenges-and-opportunities
September 11, 2019 - Commentary
Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.
Citation Text:
Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. Stud Health Technol Inform. 2024;310:324-328…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/learning-modules/nh-learning-module-guide.pdf
November 01, 2021 - Nursing Home Learning Module Guide
Nursing Home Learning Module Guide
• The Agency for Healthcare Research and Quality developed short learning modules for nursing home staff
who provide direct care to or interact with residents and their families. These brief modules address issues
many nursing homes are facing …
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide2/implguide2appb.html
September 01, 2014 - Designing Care Management Entities for Youth with Complex Behavioral Health Needs
Appendix B: Key CME Design Features in CHIPRA Quality Demonstration States, as of June 2014
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Table of Contents
Designing Care Management Entities for Youth with Complex Behavioral Health Needs
Part 1: …