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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - Study
Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.
Citation Text:
Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic…
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psnet.ahrq.gov/issue/frequency-failure-inform-patients-clinically-significant-outpatient-test-results
April 24, 2018 - Study
Frequency of failure to inform patients of clinically significant outpatient test results.
Citation Text:
Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009;169(12):1123-9. doi:10…
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psnet.ahrq.gov/issue/mixed-methods-evaluation-medication-reconciliation-primary-care-setting
November 16, 2022 - Study
A mixed methods evaluation of medication reconciliation in the primary care setting.
Citation Text:
Gionfriddo MR, Duboski V, Middernacht A, et al. A mixed methods evaluation of medication reconciliation in the primary care setting. PLoS ONE. 2021;16(12):e0260882. doi:10.1371/journ…
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psnet.ahrq.gov/issue/multi-hospital-after-observational-study-using-point-prevalence-approach-infusion-safety
January 23, 2017 - Study
A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors.
Citation Text:
Schnock KO, Dykes PC, Albert J, et al. A Multi-hospital Before-After Observational …
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psnet.ahrq.gov/issue/status-implementation-world-health-organization-multimodal-hand-hygiene-strategy-united
November 13, 2024 - Study
Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities.
Citation Text:
Allegranzi B, Conway L, Larson EL, et al. Status of the implementation of the World Health Organization multimodal hand …
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psnet.ahrq.gov/issue/patient-safety-culture-health-information-technology-implementation-and-medical-office
December 15, 2010 - Study
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
Citation Text:
Campione JR, Mardon RE, McDonald KM. Patient Safety Culture, Health Information Technology Implementation, and Medical Office Proble…
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psnet.ahrq.gov/issue/healthcare-professionals-perception-safety-culture-and-operating-room-or-black-box-technology
March 02, 2022 - Study
Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.
Citation Text:
Strandbygaard J, Dose N, Moeller KE, et al. Healthcare professionals’ perception of safety culture and th…
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psnet.ahrq.gov/issue/review-medication-errors-and-second-victim-pediatric-pharmacy
January 27, 2019 - Review
A review of medication errors and the second victim in pediatric pharmacy.
Citation Text:
Bredenkamp K, Raschka MJ, Holmes A. A review of medication errors and the second victim in pediatric pharmacy. J Pediatr Pharmacol Ther. 2024;29(2):100-106. doi:10.5863/1551-6776-29.2.100.
…
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psnet.ahrq.gov/issue/analysis-prehospital-pediatric-medication-dosing-errors-after-implementation-state-wide-ems
August 25, 2021 - Study
An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.
Citation Text:
Kazi R, Hoyle JD, Huffman C, et al. An analysis of prehospital pediatric medication dosing errors after implementation of a state-w…
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psnet.ahrq.gov/issue/improving-perceptions-patient-safety-through-standardizing-handoffs-emergency-department
December 21, 2022 - Review
Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting: a systematic review.
Citation Text:
Alimenti D, Buydos S, Cunliffe L, et al. Improving perceptions of patient safety through standardizing handoffs from t…
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psnet.ahrq.gov/issue/mortality-trends-after-voluntary-checklist-based-surgical-safety-collaborative
September 24, 2017 - Study
Classic
Mortality trends after a voluntary checklist-based surgical safety collaborative.
Citation Text:
Haynes AB, Edmondson L, Lipsitz S, et al. Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Ann Surg. 2017;266(6):923-9…
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psnet.ahrq.gov/issue/developing-and-implementing-standardized-process-global-trigger-tool-application-across-large
July 18, 2017 - Study
Developing and implementing a standardized process for Global Trigger Tool application across a large health system.
Citation Text:
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global trigger tool application across a large health …
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www.ahrq.gov/patient-safety/reports/engage/interventions/handoff-slides.html
May 01, 2017 - Warm Handoff
Patient and Family Engagement in Primary Care
Slide 1: Warm Handoff
AHRQ Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Slide 2: Speaker
Kelly Smith, PhD
Scientific Director, Quality & Safety
Co-PI, AHRQ Guide to Improve Patient Safety in …
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psnet.ahrq.gov/issue/making-inpatient-medication-reconciliation-patient-centered-clinically-relevant-and
January 14, 2009 - Commentary
Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.
Citation Text:
Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation pati…
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psnet.ahrq.gov/issue/using-potentially-aggressiveviolent-patient-huddle-improve-health-care-safety
November 16, 2022 - Commentary
Using a potentially aggressive/violent patient huddle to improve health care safety.
Citation Text:
Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety. Jt Comm J Qual Patient Saf. 2019;45(2):74-80. doi:10.…
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psnet.ahrq.gov/issue/implementation-comprehensive-unit-based-safety-program-reduce-surgical-site-infections
December 20, 2023 - Study
Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean delivery.
Citation Text:
Dieplinger B, Egger M, Jezek C, et al. Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean deli…
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psnet.ahrq.gov/issue/informatics-tools-deprescribing-and-medication-optimization-older-adults-development-and
February 05, 2020 - Study
Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.
Citation Text:
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Informatics tools in deprescribing and medication opt…
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psnet.ahrq.gov/issue/co-design-implementation-and-evaluation-serious-board-game-playdecide-patient-safety-educate
September 12, 2018 - Journal Article
The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns
Citation Text:
Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation a…
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psnet.ahrq.gov/issue/safer-paediatric-surgical-teams-5-year-evaluation-crew-resource-management-implementation-and
February 03, 2021 - Study
Safer paediatric surgical teams: a 5-year evaluation of crew resource management implementation and outcomes.
Citation Text:
Savage C, Gaffney A, Hussain-Alkhateeb L, et al. Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes…
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psnet.ahrq.gov/issue/transitioning-between-electronic-health-records-effects-ambulatory-prescribing-safety
June 03, 2013 - Study
Transitioning between electronic health records: effects on ambulatory prescribing safety.
Citation Text:
Abramson EL, Malhotra S, Fischer K, et al. Transitioning between electronic health records: effects on ambulatory prescribing safety. J Gen Intern Med. 2011;26(8):868-74. doi:1…