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psnet.ahrq.gov/node/850914/psn-pdf
June 21, 2023 - A call for safety: anticipating and mitigating risk across
an obstetrics and gynecology service line.
June 21, 2023
Combs A, Klein VR. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology
service line. J Healthc Risk Manag. 2023;43(1):38-42. doi:10.1002/jhrm.21538.
https://psnet.…
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psnet.ahrq.gov/node/46858/psn-pdf
May 11, 2019 - Evidence review conducted for the Agency for Healthcare
Research and Quality Safety Program for Improving
Surgical Care and Recovery: focus on anesthesiology for
colorectal surgery.
May 11, 2019
Ban KA, Gibbons MM, Ko CY, et al. Evidence Review Conducted for the Agency for Healthcare Research
and Quality Safety …
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psnet.ahrq.gov/node/45795/psn-pdf
May 24, 2017 - Patient Hand-Off iNitiation and Evaluation (PHONE) study:
a randomized trial of patient handoff methods.
May 24, 2017
Clanton J, Gardner A, Subichin M, et al. Patient Hand-Off iNitiation and Evaluation (PHONE) study: A
randomized trial of patient handoff methods. Am J Surg. 2017;213(2):299-306.
doi:10.1016/j.amjsu…
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psnet.ahrq.gov/node/46099/psn-pdf
May 31, 2017 - A quality improvement approach to standardization and
sustainability of the hand-off process.
May 31, 2017
Fryman C, Hamo C, Raghavan S, et al. A Quality Improvement Approach to Standardization and
Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017;6(1).
doi:10.1136/bmjquality.u222156.w8291.
https:…
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psnet.ahrq.gov/node/38596/psn-pdf
April 29, 2009 - Closing the safety loop: evaluation of the National Patient
Safety Agency's guidance regarding wristband
identification of hospital inpatients.
April 29, 2009
Sevdalis N, Norris B, Ranger C, et al. Closing the safety loop: evaluation of the National Patient Safety
Agency's guidance regarding wristband identificati…
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psnet.ahrq.gov/node/44595/psn-pdf
January 22, 2016 - Delayed rapid response team activation is associated with
increased hospital mortality, morbidity, and length of stay
in a tertiary care institution.
January 22, 2016
Barwise A, Thongprayoon C, Gajic O, et al. Delayed Rapid Response Team Activation Is Associated With
Increased Hospital Mortality, Morbidity, and Le…
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psnet.ahrq.gov/node/861289/psn-pdf
January 01, 2025 - Assessing the impact of an electronic chemotherapy
order verification checklist on pharmacist reported errors
in oncology infusion centers of a health-system.
January 24, 2024
Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order
verification checklist on pharmacist …
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psnet.ahrq.gov/node/38721/psn-pdf
June 25, 2009 - Effect of bar-code–assisted medication administration on
medication error rates in an adult medical intensive care
unit.
June 25, 2009
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on
medication error rates in an adult medical intensive care unit. Am J Health Syst Ph…
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psnet.ahrq.gov/node/43905/psn-pdf
March 04, 2015 - Suboptimal compliance with surgical safety checklists in
Colorado: a prospective observational study reveals
differences between surgical specialties.
March 4, 2015
Biffl WL, Gallagher AW, Pieracci FM, et al. Suboptimal compliance with surgical safety checklists in
Colorado: A prospective observational study revea…
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psnet.ahrq.gov/node/45072/psn-pdf
May 04, 2016 - Interventions to improve safe sleep among hospitalized
infants at eight children's hospitals.
May 4, 2016
Kuhlmann S, Ahlers-Schmidt CR, Lukasiewicz G, et al. Interventions to Improve Safe Sleep Among
Hospitalized Infants at Eight Children's Hospitals. Hosp Pediatr. 2016;6(2):88-94. doi:10.1542/hpeds.2015-
0121.
…
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psnet.ahrq.gov/node/43479/psn-pdf
October 30, 2017 - The human factor. To improve patients safety, hospitals
urged to adjust for how staff use new technology.
October 30, 2017
Rice S, Tahir D. The human factor. To improve patients safety, hospitals urged to adjust for how staff use
new technology. Modern healthcare. 2014;44(33):12-5.
https://psnet.ahrq.gov/issue/hum…
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psnet.ahrq.gov/node/867181/psn-pdf
November 20, 2024 - Leveraging consistent communication tools and
organizational values to promote accountability among
health care providers.
November 20, 2024
Baldwin CA, Krumm AM. Leveraging consistent communication tools and organizational values to promote
accountability among health care providers. AORN J. 2024;120(3):144-154. …
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psnet.ahrq.gov/node/38504/psn-pdf
September 06, 2011 - Safe Practices for Better Healthcare–2009 Update.
September 6, 2011
National Quality Forum. Washington, DC: National Quality Forum; 2009.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2009-update
The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations …
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psnet.ahrq.gov/node/36280/psn-pdf
May 27, 2011 - Types of unintended consequences related to
computerized provider order entry.
May 27, 2011
Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized
provider order entry. J Am Med Inform Assoc. 2006;13(5):547-56.
https://psnet.ahrq.gov/issue/types-unintended-consequences-rela…
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psnet.ahrq.gov/node/37869/psn-pdf
February 17, 2011 - Electronic health records in ambulatory care- a national
survey of physicians.
February 17, 2011
DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care--a national
survey of physicians. N Engl J Med. 2008;359(1):50-60. doi:10.1056/NEJMsa0802005.
https://psnet.ahrq.gov/issue/electron…
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psnet.ahrq.gov/node/838250/psn-pdf
October 06, 2022 - The impact of electronic communication of medication
discontinuation (CancelRx) on medication safety: a pilot
study.
October 6, 2022
Pitts S, Yang Y, Woodroof T, et al. The impact of electronic communication of medication discontinuation
(CancelRx) on medication safety: a pilot study. J Patient Saf. 2022;18(6):e93…
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psnet.ahrq.gov/node/866589/psn-pdf
August 28, 2024 - Developing a process to measure actual harm from
medication errors in paediatric inpatients: from design to
implementation.
August 28, 2024
Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in
paediatric inpatients: from design to implementation. Br J Clin Pharmac…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/node/852275/psn-pdf
January 01, 2024 - Improving emergency medicine clinician awareness of
prehospital-administered medications.
August 9, 2023
Kamta J, Fregoso B, Lee A, et al. Improving emergency medicine clinician awareness of prehospital-
administered medications. Prehosp Emerg Care. 2024;28(3):506-512.
doi:10.1080/10903127.2023.2238815.
https://p…
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psnet.ahrq.gov/node/37487/psn-pdf
May 26, 2011 - Predicting computerized physician order entry system
adoption in US hospitals: can the federal mandate be
met?
May 26, 2011
Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system
adoption in US hospitals: Can the federal mandate be met? Int J Med Inform. 2007;77(8).
doi:1…