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psnet.ahrq.gov/issue/use-computerized-physician-order-entry-clinical-decision-support-prevent-dose-errors
June 05, 2024 - Review
Use of computerized physician order entry with clinical decision support to prevent dose errors in pediatric medication orders: a systematic review.
Citation Text:
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical decision suppo…
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psnet.ahrq.gov/issue/computerized-dose-range-checking-using-hard-and-soft-stop-alerts-reduces-prescribing-errors
June 16, 2010 - Study
Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.
Citation Text:
Balasuriya L, Vyles D, Bakerman P, et al. Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a …
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psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient-characteristics-and
November 03, 2008 - Study
The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study.
Citation Text:
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics a…
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psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due
June 01, 2016 - Study
SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study.
Citation Text:
Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and decreas…
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psnet.ahrq.gov/issue/comprehensive-obstetric-patient-safety-program-reduces-liability-claims-and-payments
June 22, 2017 - Study
A comprehensive obstetric patient safety program reduces liability claims and payments.
Citation Text:
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.10…
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psnet.ahrq.gov/issue/influence-organizational-climate-and-clinician-morale-seclusion-and-physical-restraint-use
August 21, 2018 - Study
Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.
Citation Text:
Anderson E, Mohr DC, Regenbogen I, et al. Influence of organizational climate and clinician morale on seclusion and physical restraint use…
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psnet.ahrq.gov/issue/exploring-safety-culture-within-inpatient-mental-health-units-results-participant-observation
September 23, 2020 - Study
Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services.
Citation Text:
Molloy L, Wilson V, O'Connor MF, et al. Exploring safety culture within inpatient mental health units: the results from partic…
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psnet.ahrq.gov/issue/narrative-review-do-state-laws-make-it-easier-say-im-sorry
June 16, 2010 - Review
Narrative review: do state laws make it easier to say "I'm sorry"?
Citation Text:
McDonnell WM, Guenther E. Narrative review: do state laws make it easier to say "I'm sorry?". Ann Intern Med. 2008;149(11):811-816.
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psnet.ahrq.gov/issue/overall-performance-drug-drug-interaction-clinical-decision-support-system-quantitative
August 10, 2022 - Study
Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey.
Citation Text:
Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical decision support system: quantitative…
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psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent
January 22, 2020 - Newspaper/Magazine Article
AHRQ patient safety project reduces bloodstream infections by 40 percent.
Citation Text:
AHRQ patient safety project reduces bloodstream infections by 40 percent. Schmidt B. Patient Saf Qual Hcare. September 12, 2012.
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psnet.ahrq.gov/issue/explaining-matching-michigan-ethnographic-study-patient-safety-program
August 20, 2018 - Study
Explaining Matching Michigan: an ethnographic study of a patient safety program.
Citation Text:
Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70. doi:10.1186/1748-5908-8-70.
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psnet.ahrq.gov/issue/changes-medical-errors-after-implementation-handoff-program
April 24, 2018 - Study
Classic
Changes in medical errors after implementation of a handoff program.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803-1812. doi:10.105…
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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene
November 21, 2021 - Study
Culture change in infection control: applying psychological principles to improve hand hygiene.
Citation Text:
Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…
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psnet.ahrq.gov/issue/impact-interoperability-smart-infusion-pumps-and-electronic-medical-record-critical-care
August 25, 2021 - Study
Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.
Citation Text:
Joseph R, Lee SW, Anderson SV, et al. Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. Am J Health-System Pharm.…
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psnet.ahrq.gov/issue/patients-and-doctors-views-and-experiences-patient-safety-trajectory-breast-cancer-care
December 08, 2021 - Study
Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care.
Citation Text:
Forrest C, O'Sullivan MJ, Ryan M, et al. Patients' and doctors’ views and experiences of the patient safety trajectory of breast cancer care. Breast. 2024;75:103699. …
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
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Maternal Safety
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
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psnet.ahrq.gov/node/38202/psn-pdf
November 12, 2008 - The tipping point: the relationship between volume and
patient harm.
November 12, 2008
Pedroja AT. The tipping point: the relationship between volume and patient harm. Am J Med Qual.
2008;23(5):336-41. doi:10.1177/1062860608320628.
https://psnet.ahrq.gov/issue/tipping-point-relationship-between-volume-and-patient-…
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psnet.ahrq.gov/node/36216/psn-pdf
August 03, 2012 - Hospital Medication Errors Commonplace.
August 3, 2012
Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006.
https://psnet.ahrq.gov/issue/hospital-medication-errors-commonplace
This segment features Donald Berwick, David Bates, and other experts discussing the Institute of Medicine
(IOM) report Prev…
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psnet.ahrq.gov/node/41197/psn-pdf
March 07, 2012 - Fear of punitive response to hospital errors lingers.
March 7, 2012
O'Reilly KB. American Medical News. February 20, 2012.
https://psnet.ahrq.gov/issue/fear-punitive-response-hospital-errors-lingers
This news article highlights the problem of blame culture in health care, which hinders incident reporting
and safet…