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digital.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf
May 01, 2012 - The Patient Safety Act focuses on
learning from retrospective analysis of safety incidents and adverse … (The EHRevent incident reporting system focuses on incidents where patients are
harmed, rather than … Manager 2.0 no longer asks users to classify what type of care-process compromise occurred and
instead focuses … • In Progress
• Case closed: resolved
• Case closed: not resolved
The Hazard Manager 2.0 now focuses
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psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
January 21, 2019 - Study
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
Citation Text:
Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
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psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-systematic-review
September 29, 2021 - Review
Interventions to improve team effectiveness: a systematic review.
Citation Text:
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95. doi:10.1016/j.healthpol…
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psnet.ahrq.gov/issue/error-stress-and-teamwork-medicine-and-aviation-cross-sectional-surveys
June 16, 2011 - Study
Classic
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Citation Text:
Sexton JB. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2002;320(7237):745-749. doi:10.1136/bmj.320.7237.745.
C…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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Fo…
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psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration-contributes-and
February 12, 2020 - Study
The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.
Citation Text:
Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusi…
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psnet.ahrq.gov/issue/safer-prescribing-and-care-elderly-space-cluster-randomised-controlled-trial-general-practice
November 18, 2020 - Study
Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.
Citation Text:
Wallis KA, Elley CR, Moyes SA, et al. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. BJGP Open. …
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psnet.ahrq.gov/issue/effect-electronic-transmission-prescriptions-dispensing-errors-and-prescription-enhancements
December 16, 2020 - Study
The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.
Citation Text:
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission…
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psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality
April 22, 2011 - Study
The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.
Citation Text:
Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:1…
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psnet.ahrq.gov/issue/impact-80-hour-resident-workweek-surgical-residents-and-attending-surgeons
January 04, 2010 - Study
The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Citation Text:
Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 8…
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psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
May 23, 2018 - Study
Performance of a trigger tool for identifying adverse events in oncology.
Citation Text:
Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634.
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psnet.ahrq.gov/issue/simulation-based-clinical-systems-testing-healthcare-spaces-intake-through-implementation
April 10, 2024 - Commentary
Emerging Classic
Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.
Citation Text:
Colman N, Doughty C, Arnold J, et al. Simulation-based clinical systems testing for healthcare spaces: from intake thr…
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psnet.ahrq.gov/issue/development-research-agenda-identify-evidence-based-strategies-improve-physician-wellness-and
June 01, 2022 - Commentary
Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout.
Citation Text:
Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness an…
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psnet.ahrq.gov/issue/patient-perspectives-how-physicians-communicate-diagnostic-uncertainty-experimental-vignette
August 07, 2019 - Study
Classic
Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study.
Citation Text:
Bhise V, Meyer AND, Menon S, et al. Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental…
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psnet.ahrq.gov/issue/registered-nurses-efforts-ensure-safety-home-dwelling-older-patients
July 19, 2019 - Study
Registered nurses' efforts to ensure safety for home-dwelling older patients.
Citation Text:
Lindberg C, Fock J, Nilsen P, et al. Registered nurses' efforts to ensure safety for home‐dwelling older patients. Scand J Caring Sci. 2022. doi:10.1111/scs.13142.
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Forma…
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psnet.ahrq.gov/issue/health-care-provider-factors-associated-patient-reported-adverse-events-and-harm
June 19, 2019 - Study
Health care provider factors associated with patient-reported adverse events and harm.
Citation Text:
Giardina TD, Royse KE, Khanna A, et al. Health care provider factors associated with patient-reported adverse events and harm. Jt Comm J Qual Patient Saf. 2020;46(5):282-290. doi:…
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psnet.ahrq.gov/issue/diagnostic-errors-pediatric-critical-care-systematic-review
April 06, 2016 - Review
Diagnostic errors in pediatric critical care: a systematic review.
Citation Text:
Cifra CL, Custer J, Singh H, et al. Diagnostic errors in pediatric critical care: a systematic review. Pediatr Crit Care Med. 2021;22(8):701-712. doi:10.1097/pcc.0000000000002735.
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…
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psnet.ahrq.gov/issue/communication-safe-caregiving-between-community-nurse-case-managers-and-family-caregivers
March 09, 2022 - Study
Communication on safe caregiving between community nurse case managers and family caregivers.
Citation Text:
Macías-Colorado ME, Rodríguez-Pérez M, Rojas-Ocaña MJ, et al. Communication on safe caregiving between community nurse case managers and family caregivers. Healthcare (Basel…
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psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
December 04, 2016 - Study
Patients' perception of types of errors in palliative care—results from a qualitative interview study.
Citation Text:
Kiesewetter I, Schulz CM, Bausewein C, et al. Patients' perception of types of errors in palliative care - results from a qualitative interview study. BMC Palliat C…
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psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles-potential-co
September 23, 2020 - Study
Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience.
Citation Text:
Øyri SF, Braut GS, Macrae C, et al. Investigating Hospital Supervision: A Case Study of Regulatory Inspectors’ Roles as Potential Co-creators of R…