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psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call
March 13, 2015 - Study
Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety.
Citation Text:
Bucaro PJ, Black E. Facilitating a safe transition from the pediatric emergency department to …
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psnet.ahrq.gov/issue/patient-factors-associated-new-prescribing-potentially-inappropriate-medications-multimorbid
August 18, 2021 - Study
Patient factors associated with new prescribing of potentially inappropriate medications in multimorbid US older adults using multiple medications.
Citation Text:
Jungo KT, Streit S, Lauffenburger JC. Patient factors associated with new prescribing of potentially inappropriate medi…
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psnet.ahrq.gov/issue/ten-years-online-incident-reporting-and-learning-using-cpirls-implications-improved-patient
December 23, 2020 - Study
Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.
Citation Text:
Thomas M, Swait G, Finch R. Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. Chiropr Man Therap. 202…
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psnet.ahrq.gov/issue/unpacking-complexity-covid-19-fatalities-adverse-events-contributing-factors-single-center
January 25, 2023 - Study
Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic.
Citation Text:
Zińczuk A, Rorat M, Simon K, et al. Unpacking the complexity of COVID-19 fatalities: adverse event…
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psnet.ahrq.gov/issue/prevalence-medical-error-related-end-life-communication-canadian-hospitals-results
November 23, 2016 - Study
Classic
The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study.
Citation Text:
Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life comm…
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psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
April 27, 2022 - Commentary
Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.
Citation Text:
Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…
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psnet.ahrq.gov/issue/antimicrobial-residual-drug-error-intensive-care-unit-single-blinded-prospective
November 21, 2021 - Study
Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study.
Citation Text:
Jarrett P, Keogh S, Roberts JA, et al. Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. Inte…
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psnet.ahrq.gov/issue/what-known-about-adverse-events-older-medical-hospital-inpatients-systematic-review
January 12, 2012 - Review
What is known about adverse events in older medical hospital inpatients? A systematic review of the literature.
Citation Text:
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. Int J He…
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psnet.ahrq.gov/issue/what-can-we-learn-about-patient-safety-information-sources-within-acute-hospital-step-ladder
October 09, 2024 - Study
What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?
Citation Text:
Hogan H, Olsen S, Scobie S, et al. What can we learn about patient safety from information sources within an acute hospital…
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psnet.ahrq.gov/issue/trust-temporality-and-systems-how-do-patients-understand-patient-safety-primary-care
February 09, 2016 - Study
Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.
Citation Text:
Rhodes P, Campbell S, Sanders C. Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. Health Exp…
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psnet.ahrq.gov/issue/changes-hospital-adverse-events-and-patient-outcomes-associated-private-equity-acquisition
July 12, 2023 - Study
Changes in hospital adverse events and patient outcomes associated with private equity acquisition.
Citation Text:
Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365-2375. doi:10.10…
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psnet.ahrq.gov/issue/association-between-night-time-surgery-and-occurrence-intraoperative-adverse-events-and
October 13, 2021 - Study
Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.
Citation Text:
Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. Cortegi…
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psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
September 27, 2016 - Study
The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services.
Citation Text:
Vrklevski LP, McKechnie L, OʼConnor N. The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root …
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psnet.ahrq.gov/issue/polypharmacy-and-potentially-inappropriate-medication-people-dementia-nationwide-study
March 06, 2012 - Study
Emerging Classic
Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.
Citation Text:
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementi…
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psnet.ahrq.gov/node/37518/psn-pdf
March 13, 2008 - Innovation in patient safety: a new task design in
reducing patient falls.
March 13, 2008
Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care
Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5.
https://psnet.ahrq.gov/issue/innovation-patient-safety…
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psnet.ahrq.gov/node/844785/psn-pdf
September 11, 2019 - Information flow during pediatric trauma care transitions:
things falling through the cracks.
September 11, 2019
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Information flow during pediatric trauma care transitions:
things falling through the cracks. Intern Emerg Med. 2019;14(5):797-805. doi:10.1007/s11739-019-0…
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psnet.ahrq.gov/node/40454/psn-pdf
June 01, 2012 - Influence of unit-level staffing on medication errors and
falls in military hospitals.
June 1, 2012
Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and
falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090.
https://psne…
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psnet.ahrq.gov/node/39255/psn-pdf
February 02, 2011 - The patient who falls: "It's always a trade-off."
February 2, 2011
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66.
doi:10.1001/jama.2009.2024.
https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
Through a case study, this article reviews evidence on risk…
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psnet.ahrq.gov/node/47508/psn-pdf
October 24, 2018 - Root cause analysis of reported patient falls in ORs in the
Veterans Health Administration.
October 24, 2018
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the
Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/41554/psn-pdf
January 03, 2017 - Using root cause analysis to reduce falls with injury in
community settings.
January 3, 2017
Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt
Comm J Qual Patient Saf. 2012;38(8):366-374.
https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-inj…