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psnet.ahrq.gov/node/847718/psn-pdf
April 19, 2023 - Effect of a Veterans Health Administration mandate to
case review patients with opioid prescriptions on
mortality among patients with opioid use disorder: a
secondary analysis of the STORM randomized control
trial.
April 19, 2023
Auty SG, Barr KD, Frakt AB, et al. Effect of a Veterans Health Administration mandat…
-
psnet.ahrq.gov/node/46404/psn-pdf
December 07, 2017 - Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum.
December 7, 2017
Lipitz-Snyderman A, Pfister D, Classen D, et al. Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum. Cancer. 2017;123(23):4728-4736. doi:10.1002/…
-
psnet.ahrq.gov/node/47088/psn-pdf
May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018
User Database Report.
May 2, 2018
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2018. AHRQ Publication No. 18-0030-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…
-
psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - Suicide attempts and completions on medical-surgical
and intensive care units.
September 19, 2016
Mills PD, Watts V, Hemphill RR. Suicide attempts and completions on medical-surgical and intensive care
units. J Hosp Med. 2014;9(3):182-5. doi:10.1002/jhm.2141.
https://psnet.ahrq.gov/issue/suicide-attempts-and-compl…
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psnet.ahrq.gov/node/41539/psn-pdf
January 07, 2015 - Dying for the weekend: a retrospective cohort study on
the association between day of hospital presentation and
the quality and safety of stroke care.
January 7, 2015
Palmer WL, Bottle A, Davie C, et al. Dying for the weekend: a retrospective cohort study on the association
between day of hospital presentation and…
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psnet.ahrq.gov/node/42693/psn-pdf
December 23, 2016 - Preventing unintended retained foreign objects.
December 23, 2016
Preventing unintended retained foreign objects. Sentinel event alert. 2013;(51):1-5.
https://psnet.ahrq.gov/issue/preventing-unintended-retained-foreign-objects
Sentinel event alerts are issued periodically by The Joint Commission to identify common …
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psnet.ahrq.gov/node/40726/psn-pdf
July 03, 2014 - Automated identification of postoperative complications
within an electronic medical record using natural
language processing.
July 3, 2014
Murff HJ, FitzHenry F, Matheny ME, et al. Automated identification of postoperative complications within an
electronic medical record using natural language processing. JAMA. …
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psnet.ahrq.gov/node/60562/psn-pdf
June 03, 2020 - A case-controlled study of relatives' complaints
concerning patients who died in hospital: the role of
treatment escalation/limitation planning.
June 3, 2020
Taylor DR, Bouttell J, Campbell JN, et al. A case-controlled study of relatives’ complaints concerning
patients who died in hospital: the role of treatment e…
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psnet.ahrq.gov/node/845357/psn-pdf
March 29, 2023 - Reducing hospital harm: establishing a command centre
to foster situational awareness.
March 29, 2023
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc
Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
https://psnet.ahrq.gov/innovation/reducing-hospital-harm-…
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psnet.ahrq.gov/node/41226/psn-pdf
April 22, 2012 - Defining impact of a rapid response team: qualitative
study with nurses, physicians and hospital
administrators.
April 22, 2012
Benin AL, Borgstrom CP, Jenq GY, et al. Defining impact of a rapid response team: qualitative study with
nurses, physicians and hospital administrators. BMJ Qual Saf. 2012;21(5):391-8. do…
-
psnet.ahrq.gov/node/866191/psn-pdf
June 26, 2024 - Quality improvement lessons learned from National
Implementation of the "Patient Safety Events in
Community Care: Reporting, Investigation, and
Improvement Guidebook".
June 26, 2024
Sullivan JL, Shin MH, Chan J, et al. Quality improvement lessons learned from National Implementation of
the “Patient Safety Events …
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psnet.ahrq.gov/node/43016/psn-pdf
May 28, 2014 - Identification of serious and reportable events in home
care: a Delphi survey to develop consensus.
May 28, 2014
Doran DM, Baker R, Szabo C, et al. Identification of serious and reportable events in home care: a Delphi
survey to develop consensus. Int J Health Care Qual. 2014;26(2):136-143. doi:10.1093/intqhc/mzu00…
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psnet.ahrq.gov/node/43207/psn-pdf
April 25, 2016 - Root cause analysis of serious adverse events among
older patients in the Veterans Health Administration.
April 25, 2016
Lee A, Mills PD, Neily J, et al. Root cause analysis of serious adverse events among older patients in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2014;40(6):253-62.
https://…
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psnet.ahrq.gov/node/40785/psn-pdf
May 04, 2012 - A framework for evaluating the appropriateness of clinical
decision support alerts and responses.
May 4, 2012
McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical
decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl-
2011-…
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psnet.ahrq.gov/node/45814/psn-pdf
March 22, 2017 - Emergency medical services responders' perceptions of
the effect of stress and anxiety on patient safety in the
out-of-hospital emergency care of children: a qualitative
study.
March 22, 2017
Guise J-M, Hansen M, O'Brien K, et al. Emergency medical services responders' perceptions of the effect
of stress and anxi…
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psnet.ahrq.gov/node/45905/psn-pdf
December 22, 2017 - Safe practice recommendations for the use of copy-
forward with nursing flow sheets in hospital settings.
December 22, 2017
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward
with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qual Patient Saf. 2017;43(8):375…
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/42118/psn-pdf
March 20, 2013 - Simulation exercises as a patient safety strategy: a
systematic review.
March 20, 2013
Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):426-32. doi:10.7326/0003-4819-158-5-201303051-
00010.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47609/psn-pdf
December 19, 2018 - Nurse Staffing Levels, Missed Vital Signs and Mortality in
Hospitals: Retrospective Longitudinal Observational
Study.
December 19, 2018
Griffiths P, Ball JE, Bloor K, et al. Nurse Staffing Levels, Missed Vital Signs And Mortality In Hospitals:
Retrospective Longitudinal Observational Study. Southampton, UK: NIHR J…
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psnet.ahrq.gov/node/844801/psn-pdf
January 01, 2021 - A mixed-methods study of challenges experienced by
clinical teams in measuring improvement.
September 11, 2019
Woodcock T, Liberati EG, Dixon-Woods M. A mixed-methods study of challenges experienced by clinical
teams in measuring improvement. BMJ Qual Saf. 2021;30(2):106-115. doi:10.1136/bmjqs-2018-009048.
https:/…