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psnet.ahrq.gov/node/44733/psn-pdf
December 07, 2018 - Patient Safety in Ambulatory Settings: Technical Brief.
December 7, 2018
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19,
2016.
https://psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
The primary focus on patient safety research has been…
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psnet.ahrq.gov/node/40294/psn-pdf
September 24, 2016 - Hospital doctors' workflow interruptions and activities: an
observation study.
September 24, 2016
Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation
study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281.
https://psnet.ahrq.gov/issue/hospital-d…
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psnet.ahrq.gov/node/45194/psn-pdf
December 14, 2016 - Wounded care: failure at one Indian Health Service
hospital reveals a system in crisis.
December 14, 2016
Herman B, Fei F. Mod Healthc. December 2, 2016.
https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis
Underserved communities face challenges to receiving h…
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psnet.ahrq.gov/node/46331/psn-pdf
September 14, 2018 - Health IT Patient Safety Supplemental Items for Hospitals.
September 14, 2018
Agency for Healthcare Research and Quality. July 25, 2018.
https://psnet.ahrq.gov/issue/health-it-patient-safety-supplemental-items-hospitals
Tracking the intersection of organizational culture with health information technology use can …
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm
Fatigue
May 1, 2016
Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet].
2016.
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
Perspective
Alarm fatigue occurs whe…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.In Conversation with...James L. Reinertsen, MD. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/issue/surgeons-disclosures-clinical-adverse-events
August 18, 2021 - Study
Surgeons' disclosures of clinical adverse events.
Citation Text:
Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. 2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787.
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psnet.ahrq.gov/issue/doing-right-things-and-doing-them-right-way-association-between-hospital-guideline-adherence
February 03, 2011 - Study
Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome.
Citation Text:
Mehta RH, Chen AY, Alexander KP, et al. Doing the right things and doing them the right way…
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psnet.ahrq.gov/issue/measuring-teamwork-health-care-settings-review-survey-instruments
December 14, 2016 - Review
Measuring teamwork in health care settings: a review of survey instruments.
Citation Text:
Valentine MA, Nembhard IM, Edmondson A. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16-e30. doi:10.1097/MLR.0b013e31827feef6.
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psnet.ahrq.gov/issue/four-years-experience-hospitalist-led-medical-emergency-team-interrupted-time-series
October 03, 2011 - Study
Four years' experience with a hospitalist-led medical emergency team: an interrupted time series.
Citation Text:
Rothberg MB, Belforti R, Fitzgerald J, et al. Four years' experience with a hospitalist-led medical emergency team: an interrupted time series. J Hosp Med. 2012;7(2):9…
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psnet.ahrq.gov/issue/whos-covering-our-loved-ones-surprising-barriers-sign-out-process
October 19, 2022 - Study
Who's covering our loved ones: surprising barriers in the sign-out process.
Citation Text:
Antonoff MB, Berdan EA, Kirchner VA, et al. Who's covering our loved ones: surprising barriers in the sign-out process. Am J Surg. 2013;205(1):77-84. doi:10.1016/j.amjsurg.2012.05.009.
Co…
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psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-programmes-hospital-transitions-systematic-review-and
April 18, 2018 - Review
Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.
Citation Text:
Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.…
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psnet.ahrq.gov/issue/interdisciplinary-icu-cardiac-arrest-debriefing-improves-survival-outcomes
September 02, 2020 - Study
Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes.
Citation Text:
Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42(7):1688-95. doi:10.1097/CCM.0000000000000327.
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psnet.ahrq.gov/issue/nurse-burnout-predicts-self-reported-medication-administration-errors-acute-care-hospitals
August 25, 2021 - Study
Nurse burnout predicts self-reported medication administration errors in acute care hospitals.
Citation Text:
Montgomery AP, Azuero A, Baernholdt MB, et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J Healthc Qual. 2020;43(1):13…
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psnet.ahrq.gov/issue/monitoring-and-reducing-central-line-associated-bloodstream-infections-national-survey-state
December 01, 2010 - Study
Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.
Citation Text:
Murphy DJ, Needham DM, Goeschel CA, et al. Monitoring and reducing central line-associated bloodstream infections: a national survey of state h…
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psnet.ahrq.gov/issue/hand-hygiene-and-healthcare-system-change-within-multi-modal-promotion-narrative-review
January 05, 2012 - Review
Hand hygiene and healthcare system change within multi-modal promotion: a narrative review.
Citation Text:
Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect. 2013;83 Suppl 1:S3-10. doi:10.1016…
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psnet.ahrq.gov/issue/inpatient-suicide-mental-health-units-veterans-affairs-va-hospitals-avoiding-environmental
September 05, 2018 - Study
Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.
Citation Text:
Mills PD, King LA, Watts B, et al. Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. Gen Hosp Psych…
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psnet.ahrq.gov/issue/patient-perception-fall-risk-and-fall-risk-screening-scores
December 07, 2022 - Study
Patient perception of fall risk and fall risk screening scores.
Citation Text:
Solares NP, Calero P, Connelly CD. Patient perception of fall risk and fall risk screening scores. J Nurs Care Qual. 2023;38(2):100-106. doi:10.1097/ncq.0000000000000645.
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psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations
May 11, 2016 - Study
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
Citation Text:
Mello MM, Armstrong S, Greenberg Y, et al. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. He…