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www.ahrq.gov/patient-safety/settings/hospital/resetguide.html
July 01, 2020 - Redesigning Systems To Improve Teamwork and Quality for Hospitalized Patients (RESET Project)
A number of challenges impede hospitals’ ability to provide high-quality care to patients on medical services. Teams are large, membership changes over time, and members are often physically scattered, working across m…
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psnet.ahrq.gov/node/60202/psn-pdf
April 08, 2020 - 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
April 8, 2020
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an electronic clinical decision support
…
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psnet.ahrq.gov/node/40618/psn-pdf
August 27, 2012 - Predictors of likelihood of speaking up about safety
concerns in labour and delivery.
August 27, 2012
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799.
doi:10.1136/bmjqs.2010.050211.
https://psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-deli…
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psnet.ahrq.gov/node/46890/psn-pdf
December 21, 2018 - Physician burnout, well-being, and work unit safety
grades in relationship to reported medical errors.
December 21, 2018
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in
Relationship to Reported Medical Errors. Mayo Clin Proc. 2018;93(11):1571-1580.
doi:10.…
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psnet.ahrq.gov/node/36342/psn-pdf
March 02, 2011 - Missed and delayed diagnoses in the ambulatory setting:
a study of closed malpractice claims.
March 2, 2011
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study
of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/47333/psn-pdf
October 10, 2018 - Changing dynamics of the drug overdose epidemic in the
United States from 1979 through 2016.
October 10, 2018
Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184.
https://p…
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psnet.ahrq.gov/node/43323/psn-pdf
January 07, 2015 - Unrealized potential and residual consequences of
electronic prescribing on pharmacy workflow in the
outpatient pharmacy.
January 7, 2015
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic
prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inf…
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psnet.ahrq.gov/node/40289/psn-pdf
March 16, 2011 - Unintentional therapeutic errors involving insulin in the
ambulatory setting reported to poison centers.
March 16, 2011
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory
setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…
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psnet.ahrq.gov/node/45407/psn-pdf
September 27, 2016 - Safety of the Manchester Triage System to detect
critically ill children at the emergency department.
September 27, 2016
Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically
Ill Children at the Emergency Department. J Pediatr. 2016;177:232-237.e1.
doi:10.1016/j.j…
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psnet.ahrq.gov/node/46975/psn-pdf
November 16, 2018 - Electronic health record usability issues and potential
contribution to patient harm.
November 16, 2018
Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential
Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278. doi:10.1001/jama.2018.1171.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39548/psn-pdf
November 02, 2010 - Patient-specific electronic decision support reduces
prescription of excessive doses.
November 2, 2010
Seidling HM, Schmitt SPW, Bruckner T, et al. Patient-specific electronic decision support reduces
prescription of excessive doses. Qual Saf Health Care. 2010;19(5):e15. doi:10.1136/qshc.2009.033175.
https://psnet…
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/48030/psn-pdf
May 22, 2019 - A culture of openness is associated with lower mortality
rates among 137 English National Health Service acute
trusts.
May 22, 2019
Toffolutti V, Stuckler D. A Culture Of Openness Is Associated With Lower Mortality Rates Among 137
English National Health Service Acute Trusts. Health Aff (Millwood). 2019;38(5):844-…
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psnet.ahrq.gov/node/45901/psn-pdf
April 12, 2017 - 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.
April 12, 2017
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's
Stratifica…
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psnet.ahrq.gov/node/39031/psn-pdf
March 23, 2011 - Care homes' use of medicines study: prevalence, causes
and potential harm of medication errors in care homes for
older people.
March 23, 2011
Barber ND, Alldred DP, Raynor DK, et al. Care homes' use of medicines study: prevalence, causes and
potential harm of medication errors in care homes for older people. Qual …
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psnet.ahrq.gov/node/39171/psn-pdf
February 10, 2015 - Patient safety at ten: unmistakable progress, troubling
gaps.
February 10, 2015
Wachter R. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood).
2010;29(1):165-173. doi:10.1377/hlthaff.2009.0785.
https://psnet.ahrq.gov/issue/patient-safety-ten-unmistakable-progress-troubling-gaps
Th…
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psnet.ahrq.gov/node/43917/psn-pdf
November 03, 2015 - Underlying reasons associated with hospital readmission
following surgery in the United States.
November 3, 2015
Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following
surgery in the United States. JAMA. 2015;313(5):483-495. doi:10.1001/jama.2014.18614.
https://psnet.a…
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psnet.ahrq.gov/node/37838/psn-pdf
June 11, 2008 - Mitigation of patient harm from testing errors in family
medicine offices: a report from the American Academy of
Family Physicians National Research Network.
June 11, 2008
Graham DG, Harris DM, Elder NC, et al. Mitigation of patient harm from testing errors in family medicine
offices: a report from the American Ac…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/oXCNxbeXh-ZSDuEUzz6UQ8
Clinical Summary: Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults
Clinical Summary: Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults
Population Adults w ith a BMI ≥30a
Recommendation
Offer or refer to i…