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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
ht…
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psnet.ahrq.gov/node/73481/psn-pdf
July 07, 2021 - Leadership To Improve Diagnosis: A Call to Action.
July 7, 2021
Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality;
June 2021. AHRQ Publication No. 20(21)-0040-5-EF.
https://psnet.ahrq.gov/issue/leadership-improve-diagnosis-call-action
The mindset on diagnostic error…
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psnet.ahrq.gov/node/46261/psn-pdf
July 18, 2018 - Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a patient-centered fall prevention toolkit.
July 18, 2018
Dykes PC, Duckworth M, Cunningham S, et al. Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a Patient-Centered Fall Prevention Toolkit. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/73170/psn-pdf
April 21, 2021 - Sentinel Event Alert 63: optimizing smart infusion pump
safety with DERS.
April 21, 2021
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf.
2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
https://psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-in…
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psnet.ahrq.gov/node/38306/psn-pdf
January 07, 2009 - Impact of barcode medication administration technology
on how nurses spend their time providing patient care.
January 7, 2009
Poon EG, Keohane CA, Bane A, et al. Impact of Barcode Medication Administration Technology on How
Nurses Spend Their Time Providing Patient Care. JONA: The Journal of Nursing Administration.…
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psnet.ahrq.gov/node/866690/psn-pdf
September 11, 2024 - The effectiveness of checklists and error reporting
systems in enhancing patient safety and reducing
medical errors in hospital settings: a narrative review.
September 11, 2024
Chance EA, Florence D, Sardi Abdoul I. The effectiveness of checklists and error reporting systems in
enhancing patient safety and reducin…
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psnet.ahrq.gov/node/46354/psn-pdf
November 21, 2017 - Controlled trial to improve resident sign-out in a medical
intensive care unit.
November 21, 2017
Nanchal R, Aebly B, Graves G, et al. Controlled trial to improve resident sign-out in a medical intensive
care unit. BMJ Qual Saf. 2017;26(12):987-992. doi:10.1136/bmjqs-2017-006657.
https://psnet.ahrq.gov/issue/contr…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/847726/psn-pdf
January 01, 2024 - Systematic review of clinical debriefing tools: attributes
and evidence for use.
April 19, 2023
Phillips EC, Smith SE, Tallentire VR, et al. Systematic review of clinical debriefing tools: attributes and
evidence for use. BMJ Qual Saf. 2024;33(3):187-198. doi:10.1136/bmjqs-2022-015464.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/40286/psn-pdf
March 09, 2011 - Medication-error alerts for warfarin orders detected by a
bar-code-assisted medication administration system.
March 9, 2011
FitzHenry F, Doran J, Lobo B, et al. Medication-error alerts for warfarin orders detected by a bar-code-
assisted medication administration system. Am J Health Syst Pharm. 2011;68(5):434-41.
…
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psnet.ahrq.gov/issue/safety-risks-associated-lack-integration-and-interfacing-hospital-health-information
December 21, 2022 - Study
Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack o…
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psnet.ahrq.gov/issue/patient-outcomes-dose-reduction-or-discontinuation-long-term-opioid-therapy-systematic-review
April 08, 2019 - Review
Classic
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.
Citation Text:
Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Sys…
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psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
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psnet.ahrq.gov/issue/us-public-opinion-regarding-proposed-limits-resident-physician-work-hours
February 18, 2011 - Study
US public opinion regarding proposed limits on resident physician work hours.
Citation Text:
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
Copy Citation
Form…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Central Clinical School, Monash University
t +613 90765325 e M.Fitzgerald@alfred.org.au
Date First Implemented
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psnet.ahrq.gov/node/43885/psn-pdf
January 30, 2018 - Health Information Technology.
January 30, 2018
Am J Manag Care. 2014;20(spec 17):492-554,e1-e31.
https://psnet.ahrq.gov/issue/health-information-technology
Efforts to implement health information technology, particularly electronic health records and computerized
provider order entry systems, continue at a rapid …
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psnet.ahrq.gov/node/846764/psn-pdf
March 29, 2023 - Senators threaten consequences after VA confirms 4
deaths tied to computer system tested in Spokane.
March 29, 2023
Donovan-Smith O. Spokesman Review. March 15, 2023.
https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-
system-tested-spokane
Implementations of elec…
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psnet.ahrq.gov/node/46926/psn-pdf
March 07, 2018 - A comprehensive program to reduce rates of hospital-
acquired pressure ulcers in a system of community
hospitals.
March 7, 2018
Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital-
Acquired Pressure Ulcers in a System of Community Hospitals. J Patient Saf. 2018;14(1):54…
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psnet.ahrq.gov/node/46011/psn-pdf
January 17, 2018 - Health and Social Care Ergonomics: Patient Safety in
Practice.
January 17, 2018
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
https://psnet.ahrq.gov/issue/health-and-social-care-ergonomics-patient-safety-practice
Human factors engineering strategies offer a range of solutions to improve proce…
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psnet.ahrq.gov/node/44867/psn-pdf
March 23, 2016 - Understanding why quality initiatives succeed or fail: a
sociotechnical systems perspective.
March 23, 2016
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems
Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
https://psnet.ahrq.gov/issue/understand…