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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - May 8, 2024
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department
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psnet.ahrq.gov/node/60040/psn-pdf
March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital
Complaints.
March 11, 2020
Newcastle upon Tyne, UK: Healthwatch; January 2020.
https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints
Organizations need to do more than report and collect complaint data to realize improvements based on
what is…
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psnet.ahrq.gov/node/42893/psn-pdf
March 13, 2014 - Effect of patient safety strategies on the incidence of
adverse events.
March 13, 2014
Sierra AF, del Aguila del MR, Espigares JLN, et al. Effect of patient safety strategies on the incidence of
adverse events. J Eval Clin Pract. 2014;20(2):184-90. doi:10.1111/jep.12105.
https://psnet.ahrq.gov/issue/effect-patient…
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psnet.ahrq.gov/node/864385/psn-pdf
April 05, 2024 - Common Formats for Patient Safety Data Collection.
March 13, 2024
Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.
https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection
A standard system for voluntary reporting to patient safety organizations improves measurem…
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psnet.ahrq.gov/node/73489/psn-pdf
July 15, 2021 - A diagnostic time-out to improve differential diagnosis in
pediatric abdominal pain.
July 15, 2021
Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric
abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-0054.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/37486/psn-pdf
January 23, 2009 - Medication report reduces number of medication errors
when elderly patients are discharged from hospital.
January 23, 2009
Midlöv P, Holmdahl L, Eriksson T, et al. Medication report reduces number of medication errors when
elderly patients are discharged from hospital. Pharm World Sci. 2007;30(1):92-98. doi:10.1007…
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psnet.ahrq.gov/node/34086/psn-pdf
May 27, 2011 - Overcoming barriers to adopting and implementing
computerized physician order entry systems in U.S.
hospitals.
May 27, 2011
Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized
physician order entry systems in U.S. hospitals. Health Aff (Millwood). 2004;23(4):184-90.…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/43551/psn-pdf
January 22, 2016 - Barriers and enablers affecting patient engagement in
managing medications within specialty hospital settings.
January 22, 2016
Manias E, Rixon S, Williams A, et al. Barriers and enablers affecting patient engagement in managing
medications within specialty hospital settings. Health Expect. 2015;18(6):2787-2798.
d…
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psnet.ahrq.gov/node/837077/psn-pdf
May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes
away.
May 11, 2022
Kelman B. Kaiser Health News. April 29, 2022.
https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away
Technological solutions harbor unique risks that can result in patient harm. This article shares a response
to report…
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psnet.ahrq.gov/node/39875/psn-pdf
January 22, 2017 - Mobile in situ obstetric emergency simulation and
teamwork training to improve maternal–fetal safety in
hospitals.
January 22, 2017
Guise J-M, Lowe NK, Deering S, et al. Mobile in situ obstetric emergency simulation and teamwork training
to improve maternal-fetal safety in hospitals. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/44863/psn-pdf
July 01, 2016 - Rating the raters: the inconsistent quality of health care
performance measurement.
July 1, 2016
Shahian DM, Normand S-LT, Friedberg MW, et al. Rating the Raters: The Inconsistent Quality of Health
Care Performance Measurement. Ann Surg. 2016;264(1):36-8. doi:10.1097/SLA.0000000000001631.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44564/psn-pdf
October 14, 2015 - Reducing falls with a safety spotter program.
October 14, 2015
Primmer P, Borenstein KK, Downing MT, et al. Reducing falls with a safety spotter program. Nursing
(Brux). 2015;45(8):16-9. doi:10.1097/01.NURSE.0000469244.89222.27.
https://psnet.ahrq.gov/issue/reducing-falls-safety-spotter-program
Patients at high ri…
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psnet.ahrq.gov/node/44190/psn-pdf
June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce
hospital errors.
June 3, 2015
Takahara D. KDVR. May 19, 2015.
https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors
Parents of children who experience harm in the course of medical care serve as advocates to drive saf…
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psnet.ahrq.gov/node/34033/psn-pdf
April 11, 2011 - Adverse events and preventable adverse events in
children.
April 11, 2011
Woods D, Thomas EJ, Holl JL, et al. Adverse events and preventable adverse events in children.
Pediatrics. 2005;115(1):155-60.
https://psnet.ahrq.gov/issue/adverse-events-and-preventable-adverse-events-children
Adverse events in hospitalize…
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psnet.ahrq.gov/node/45326/psn-pdf
January 03, 2017 - Consumer rankings and health care: toward validation
and transparency.
January 3, 2017
Hota B, Webb TA, Stein BD, et al. Consumer Rankings and Health Care: Toward Validation and
Transparency. Jt Comm J Qual Patient Saf. 2016;42(10):439-446.
https://psnet.ahrq.gov/issue/consumer-rankings-and-health-care-toward-vali…
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psnet.ahrq.gov/node/45070/psn-pdf
October 03, 2017 - When There's Harm in the Hospital: Can Transparency
Replace "Deny and Defend"?
October 3, 2017
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend
This report provides the insight…
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psnet.ahrq.gov/node/44145/psn-pdf
September 27, 2017 - Nurse staffing levels and patient-reported missed nursing
care.
September 27, 2017
Dabney BW, Kalisch BJ. Nurse Staffing Levels and Patient-Reported Missed Nursing Care. J Nurs Care
Qual. 2015;30(4):306-12. doi:10.1097/NCQ.0000000000000123.
https://psnet.ahrq.gov/issue/nurse-staffing-levels-and-patient-reported-mi…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
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Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…