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psnet.ahrq.gov/node/39877/psn-pdf
September 29, 2010 - Detection of postoperative respiratory failure: how
predictive is the Agency for Healthcare Research and
Quality's Patient Safety Indicator?
September 29, 2010
Utter GH, Cuny J, Sama P, et al. Detection of postoperative respiratory failure: how predictive is the
Agency for Healthcare Research and Quality's Patient…
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psnet.ahrq.gov/node/72674/psn-pdf
January 27, 2021 - The effect of blue-enriched lighting on medical error rate
in a university hospital ICU.
January 27, 2021
Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a
University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j.jcjq.2020.11.007.
https://psne…
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psnet.ahrq.gov/node/43291/psn-pdf
June 25, 2014 - The interpretability of doctor identification badges in UK
hospitals: a survey of nurses and patients.
June 25, 2014
Hickerton BC, Fitzgerald DJ, Perry E, et al. The interpretability of doctor identification badges in UK
hospitals: a survey of nurses and patients. BMJ Qual Saf. 2014;23(7):543-7. doi:10.1136/bmjqs-2…
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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/42535/psn-pdf
October 16, 2013 - Implementing an interprofessional patient safety learning
initiative: insights from participants, project leads and
steering committee members.
October 16, 2013
Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative:
insights from participants, project leads an…
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psnet.ahrq.gov/node/44333/psn-pdf
July 15, 2015 - One hospital's initiatives to encourage safe opioid use.
July 15, 2015
Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs.
2015;38(4):278-83. doi:10.1097/NAN.0000000000000110.
https://psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
This commentar…
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psnet.ahrq.gov/node/41006/psn-pdf
December 21, 2011 - Failure to notify reportable test results: significance in
medical malpractice.
December 21, 2011
Gale BD, Bissett-Siegel DP, Davidson SJ, et al. Failure to notify reportable test results: significance in
medical malpractice. J Am Coll Radiol. 2011;8(11):776-9. doi:10.1016/j.jacr.2011.06.023.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/41406/psn-pdf
August 02, 2012 - Can patients report patient safety incidents in a hospital
setting? A systematic review.
August 2, 2012
Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic
review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213.
https://psnet.ahrq.gov/issue/can-pati…
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psnet.ahrq.gov/node/47551/psn-pdf
April 08, 2019 - Factors impacting physician use of information charted
by others.
April 8, 2019
Zozus MN, Penning M, Hammond WE. JAMIA Open. 2019;2:107-114.
https://psnet.ahrq.gov/issue/factors-impacting-physician-use-information-charted-others
The copy-and-paste phenomenon in clinical documentation can result in perpetuating inc…
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psnet.ahrq.gov/node/846168/psn-pdf
March 15, 2023 - Now is the time to routinely ask patients about safety.
March 15, 2023
Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf.
2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009.
https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety
Safety event reporting …
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psnet.ahrq.gov/node/43821/psn-pdf
April 25, 2016 - Navigating care transitions: a process model of how
doctors overcome organizational barriers and create
awareness.
April 25, 2016
Hilligoss B, Vogus TJ. Navigating Care Transitions. Medical Care Research and Review. 2014;72(1).
doi:10.1177/1077558714563170.
https://psnet.ahrq.gov/issue/navigating-care-transitions…
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psnet.ahrq.gov/node/43889/psn-pdf
February 11, 2015 - Data as a catalyst for change: stories from the frontlines.
February 11, 2015
Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk Manag.
2015;34(3):18-25. doi:10.1002/jhrm.21161.
https://psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines
Analysis of malpractice c…
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psnet.ahrq.gov/node/40758/psn-pdf
September 07, 2011 - A review of educational strategies to improve nurses'
roles in recognizing and responding to deteriorating
patients.
September 7, 2011
Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles
in recognizing and responding to deteriorating patients. Int Nurs Rev. 20…
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psnet.ahrq.gov/node/47221/psn-pdf
August 29, 2018 - Barriers and facilitators to injection safety in ambulatory
care settings.
August 29, 2018
Leback C, Johnson DH, Anderson L, et al. Barriers and Facilitators to Injection Safety in Ambulatory Care
Settings. Infect Control Hosp Epidemiol. 2018;39(7):841-848. doi:10.1017/ice.2018.82.
https://psnet.ahrq.gov/issue/bar…
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psnet.ahrq.gov/node/40944/psn-pdf
March 06, 2012 - Using the Agency for Healthcare Research and Quality
Patient Safety Indicators for targeting nursing quality
improvement.
March 6, 2012
Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient
safety indicators for targeting nursing quality improvement. J Nurs Care Qual. …
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/43743/psn-pdf
December 03, 2014 - Conflict of interest, Dr Charles Denham and the Journal of
Patient Safety.
December 3, 2014
Wu AW, Kavanagh KT, Pronovost P, et al. Conflict of interest, Dr Charles Denham and the Journal of
Patient Safety. J Patient Saf. 2014;10(4):181-5. doi:10.1097/PTS.0000000000000144.
https://psnet.ahrq.gov/issue/conflict-int…
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psnet.ahrq.gov/node/44473/psn-pdf
September 27, 2016 - Medication errors in hospitals: a literature review of
disruptions to nursing practice during medication
administration.
September 27, 2016
Hayes C, Jackson D, Davidson PM, et al. Medication errors in hospitals: a literature review of disruptions to
nursing practice during medication administration. J Clin Nurs. 2…
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psnet.ahrq.gov/node/47332/psn-pdf
November 02, 2018 - Interventions for postsurgical opioid prescribing: a
systematic review.
November 2, 2018
Wick EC, Sehgal NL. A Learning Health System Approach to the Opioid Crisis. JAMA Surg.
2018;153(10):948-954. doi:10.1001/jamasurg.2018.2731.
https://psnet.ahrq.gov/issue/interventions-postsurgical-opioid-prescribing-systematic…
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psnet.ahrq.gov/node/73678/psn-pdf
September 08, 2021 - A report of information technology and health
deficiencies in U.S. nursing homes.
September 8, 2021
Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing
homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390.
https://psnet.ahrq.gov/issue/report-i…