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psnet.ahrq.gov/node/42884/psn-pdf
February 06, 2014 - Application of a theoretical framework for behavior
change to hospital workers' real-time explanations for
noncompliance with hand hygiene guidelines.
February 6, 2014
Fuller C, Besser S, Savage J, et al. Application of a theoretical framework for behavior change to hospital
workers' real-time explanations for non…
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psnet.ahrq.gov/node/60619/psn-pdf
June 24, 2020 - Analysis of iatrogenic and in-hospital medication errors
reported to United States poison centers: a retrospective
observational study.
June 24, 2020
Leonard JB, McFadden C, Feemster AA, et al. Analysis of iatrogenic and in-hospital medication errors
reported to United States poison centers: a retrospective observ…
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psnet.ahrq.gov/node/35456/psn-pdf
February 19, 2010 - The working hours of hospital staff nurses and patient
safety.
February 19, 2010
Rogers AE, Hwang W-T, Scott LD, et al. The working hours of hospital staff nurses and patient safety.
Health Aff (Millwood). 2004;23(4):202-212.
https://psnet.ahrq.gov/issue/working-hours-hospital-staff-nurses-and-patient-safety
This…
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psnet.ahrq.gov/node/843412/psn-pdf
February 01, 2023 - Patient and hospital characteristics associated with
delayed diagnosis of appendicitis.
February 1, 2023
Reyes AM, Royan R, Feinglass J, et al. Patient and hospital characteristics associated with delayed
diagnosis of appendicitis. JAMA Surg. 2023;158(3):e227055. doi:10.1001/jamasurg.2022.7055.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43098/psn-pdf
August 25, 2015 - Who do hospital physicians and nurses go to for advice
about medications? A social network analysis and
examination of prescribing error rates.
August 25, 2015
Creswick N, Westbrook JI. Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A
Social Network Analysis and Examination of Prescribin…
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psnet.ahrq.gov/node/45636/psn-pdf
September 26, 2018 - Pharmacist outpatient prescription review in the
emergency department: a pediatric tertiary hospital
experience.
September 26, 2018
Shah D, Manzi S. Pharmacist Outpatient Prescription Review in the Emergency Department: A Pediatric
Tertiary Hospital Experience. Pediatr Emerg Care. 2018;34(7):497-500.
doi:10.1097/…
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psnet.ahrq.gov/node/45528/psn-pdf
October 26, 2016 - Implementing the RISE second victim support programme
at the Johns Hopkins Hospital: a case study.
October 26, 2016
Edrees HH, Connors C, Paine LA, et al. Implementing the RISE second victim support programme at the
Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. doi:10.1136/bmjopen-2016-011708.
…
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psnet.ahrq.gov/node/837675/psn-pdf
July 13, 2022 - Dashboard design to identify and balance competing risk
of multiple hospital-acquired conditions.
July 13, 2022
Makic MBF, Stevens KR, Gritz RM, et al. Dashboard design to identify and balance competing risk of
multiple hospital-acquired conditions. Appl Clin Inform. 2022;13(3):621-631. doi:10.1055/s-0042-1749598.
…
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psnet.ahrq.gov/node/36837/psn-pdf
December 03, 2018 - Hospitals as cultures of entrapment: a re-analysis of the
Bristol Royal Infirmary.
December 3, 2018
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary.
Calif Manage Rev. 2012;45(2):73-84. doi:10.2307/41166166.
https://psnet.ahrq.gov/issue/hospitals-cultures-en…
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psnet.ahrq.gov/node/45640/psn-pdf
September 01, 2018 - Case outcomes in a communication-and-resolution
program in New York hospitals.
September 1, 2018
Mello MM, Greenberg Y, Senecal SK, et al. Case Outcomes in a Communication-and-Resolution Program
in New York Hospitals. Health Serv Res. 2016;51 Suppl 3:2583-2599. doi:10.1111/1475-6773.12594.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47360/psn-pdf
June 02, 2019 - Anticoagulant medication errors in hospitals and primary
care: a cross-sectional study.
June 2, 2019
Dreijer AR, Diepstraten J, Bukkems VE, et al. Anticoagulant medication errors in hospitals and primary
care: a cross-sectional study. Int J Qual Health Care. 2019;31(5):346-352. doi:10.1093/intqhc/mzy177.
https://p…
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psnet.ahrq.gov/node/46601/psn-pdf
January 25, 2018 - Night-time communication at Stanford University
Hospital: perceptions, reality and solutions.
January 25, 2018
Sun AJ, Wang L, Go M, et al. Night-time communication at Stanford University Hospital: perceptions, reality
and solutions. BMJ Qual Saf. 2018;27(2):156-162. doi:10.1136/bmjqs-2017-006727.
https://psnet.ah…
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psnet.ahrq.gov/node/60235/psn-pdf
April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St
George’s University Hospitals NHS Foundation Trust.
April 15, 2020
NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals
NHS Foundation Trust. NHS England. March 2020.
https://psnet.ahrq.gov/issue/independent-morta…
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psnet.ahrq.gov/node/43631/psn-pdf
December 19, 2014 - An internal quality improvement collaborative
significantly reduces hospital-wide medication error
related adverse drug events.
December 19, 2014
McClead RE, Catt C, Davis T, et al. An internal quality improvement collaborative significantly reduces
hospital-wide medication error related adverse drug events. J Ped…
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psnet.ahrq.gov/node/73688/psn-pdf
September 08, 2021 - Effect of medication reconciliation on patient reported
potential adverse events after hospital discharge.
September 8, 2021
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Effect of medication reconciliation on patient reported
potential adverse events after hospital discharge. Res Social Adm Pharm. 2021;17(8):142…
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psnet.ahrq.gov/node/46187/psn-pdf
December 06, 2017 - A randomised controlled trial assessing the efficacy of an
electronic discharge communication tool for preventing
death or hospital readmission.
December 6, 2017
Santana MJ, Holroyd-Leduc J, Southern DA, et al. A randomised controlled trial assessing the efficacy of
an electronic discharge communication tool for p…
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psnet.ahrq.gov/node/42973/psn-pdf
January 01, 2015 - Patient safety climate (PSC) perceptions of frontline staff
in acute care hospitals: examining the role of ease of
reporting, unit norms of openness, and participative
leadership.
December 19, 2014
Zaheer S, Ginsburg LR, Chuang Y-T, et al. Patient safety climate (PSC) perceptions of frontline staff in
acute care …
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psnet.ahrq.gov/node/838314/psn-pdf
October 12, 2022 - Stakeholder safety communication: patient and family
reports on safety risks in hospitals.
October 12, 2022
Reader TW. Stakeholder safety communication: patient and family reports on safety risks in hospitals. J
Risk Res. 2022;25(7):807-824. doi:10.1080/13669877.2022.2061036.
https://psnet.ahrq.gov/issue/stakehold…
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Miscommunication During the Interhospital Transport of a
Critically Ill Child
August 31, 2022
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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