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psnet.ahrq.gov/node/50703/psn-pdf
December 04, 2019 - A systematic review of clinical outcomes associated with
intrahospital transitions
December 4, 2019
Bristol AA, Schneider CE, Lin S-Y, et al. A Systematic Review of Clinical Outcomes Associated With
Intrahospital Transitions. J Healthc Qual. 2019. doi:10.1097/JHQ.0000000000000232.
https://psnet.ahrq.gov/issue/syst…
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psnet.ahrq.gov/node/73092/psn-pdf
March 31, 2021 - SAFER Care: improving caregiver comprehension of
discharge instructions.
March 31, 2021
Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge
instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031.
https://psnet.ahrq.gov/issue/safer-care-improving-careg…
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psnet.ahrq.gov/node/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…
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psnet.ahrq.gov/node/41679/psn-pdf
April 17, 2013 - Impact of participation in the California Healthcare-
Associated Infection Prevention Initiative on adoption and
implementation of evidence-based practices for patient
safety and health care–associated infection rates in a
cohort of acute care general hospitals.
April 17, 2013
Halpin HA, McMenamin SB, Simon LP, e…
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psnet.ahrq.gov/node/42513/psn-pdf
January 15, 2014 - A comprehensive patient safety program can significantly
reduce preventable harm, associated costs, and hospital
mortality.
January 15, 2014
Brilli RJ, McClead RE, Crandall W, et al. A comprehensive patient safety program can significantly reduce
preventable harm, associated costs, and hospital mortality. J Pediat…
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psnet.ahrq.gov/node/60803/psn-pdf
August 12, 2020 - Interprofessional/interdisciplinary teamwork during the
early COVID-19 pandemic: experience from a children's
hospital within an academic health center.
August 12, 2020
Natale JAE, Boehmer J, Blumberg DA, et al. Interprofessional/interdisciplinary teamwork during the early
COVID-19 pandemic: experience from a chil…
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psnet.ahrq.gov/node/865526/psn-pdf
April 10, 2024 - Rural emergency medical services clinicians' perceptions
and preferences in receiving clinical feedback from
hospitals: a qualitative needs assessment.
April 10, 2024
Schneider K, Williams M, Mohr NM, et al. Rural emergency medical services clinicians' perceptions and
preferences in receiving clinical feedback fro…
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psnet.ahrq.gov/node/47158/psn-pdf
August 15, 2018 - A standardized handoff simulation promotes recovery
from auditory distractions in resident physicians.
August 15, 2018
Matern LH, Farnan JM, Hirsch KW, et al. A Standardized Handoff Simulation Promotes Recovery From
Auditory Distractions in Resident Physicians. Simul Healthc. 2018;13(4):233-238.
doi:10.1097/SIH.00…
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psnet.ahrq.gov/node/837597/psn-pdf
June 29, 2022 - Patient safety informatics: criteria development for
assessing the maturity of digital patient safety in
hospitals.
June 29, 2022
Kutza J-O, Hübner U, Holmgren AJ, et al. Patient safety informatics: criteria development for assessing the
maturity of digital patient safety in hospitals. Stud Health Technol Inform. …
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-database-report
April 22, 2018 - Book/Report
Medical Office Survey on Patient Safety Culture: 2018 User Database Report.
Citation Text:
Medical Office Survey on Patient Safety Culture: 2018 User Database Report. Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AH…
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psnet.ahrq.gov/issue/american-college-surgeons-committee-trauma-performance-improvement-and-patient-safety-program
September 23, 2020 - Study
American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center.
Citation Text:
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma Performance Improvem…
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psnet.ahrq.gov/issue/adherence-drug-drug-interaction-alerts-high-risk-patients-trial-context-enhanced-alerting
February 21, 2018 - Study
Adherence to drug–drug interaction alerts in high-risk patients: a trial of context-enhanced alerting.
Citation Text:
Duke JD, Li X, Dexter P. Adherence to drug-drug interaction alerts in high-risk patients: a trial of context-enhanced alerting. J Am Med Inform Assoc. 2013;20(3):49…
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psnet.ahrq.gov/issue/importance-prevention-and-early-intervention-adverse-events-pediatric-cardiac-catheterization
March 24, 2019 - Study
Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years of experience.
Citation Text:
Huang Y-C, Chang J-S, Lai Y-C, et al. Importance of prevention and early intervention of adverse events in pediatric cardi…
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psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-uptake-patient-safety-and-cost-control-functions
July 25, 2011 - Commentary
Incomplete EHR adoption: late uptake of patient safety and cost control functions.
Citation Text:
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost control functions. Am J Med Qual. 2007;22(5):319-26.
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…
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psnet.ahrq.gov/issue/measuring-adverse-events-and-levels-harm-pediatric-inpatients-global-trigger-tool
December 18, 2013 - Study
Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool.
Citation Text:
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e12…
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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/leadership-and-high-reliability-transformation-qualitative-study-truman-va-medical-center
May 31, 2023 - Study
Leadership and the high reliability transformation: a qualitative study at Truman VA medical center.
Citation Text:
Leonard C, Gilmartin HM, Starr LM, et al. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2…
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psnet.ahrq.gov/issue/relationship-between-preventability-death-after-coronary-artery-bypass-graft-surgery-and-all
September 23, 2020 - Study
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.
Citation Text:
Guru V, Tu J, Etchells E, et al. Relationship between preventability of death after coronary artery bypass graft surgery and all-cau…