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psnet.ahrq.gov/issue/identifying-electronic-medication-administration-record-emar-usability-issues-patient-safety
July 07, 2021 - Study
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.
Citation Text:
Iqbal AR, Parau CA, Kazi S, et al. Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. Jt…
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psnet.ahrq.gov/issue/scaling-diagnostic-pause-icu-ward-transition-exploration-barriers-and-facilitators
July 19, 2019 - Study
Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.
Citation Text:
Cornell EG, Harris E, McCune E, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploratio…
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psnet.ahrq.gov/issue/how-best-measure-surgical-quality-comparison-agency-healthcare-research-and-quality-patient
December 21, 2014 - Study
How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.
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psnet.ahrq.gov/issue/never-events-uk-general-practice-survey-views-general-practitioners-their-frequency-and
June 30, 2021 - Study
Never events in UK general practice: A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach
Citation Text:
Stocks SJ, Alam R, Bowie P, et al. Never Events in UK General Practice: A Survey of the Views of General Practiti…
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psnet.ahrq.gov/issue/association-web-based-handoff-tool-rates-medical-errors
April 12, 2023 - Study
Association of a web-based handoff tool with rates of medical errors.
Citation Text:
Mueller SK, Yoon CS, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical Errors. JAMA Intern Med. 2016;176(9):1400-2. doi:10.1001/jamainternmed.2016.4258.
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psnet.ahrq.gov/issue/implementation-discharge-education-program-improve-transitions-care-patients-high-risk
January 12, 2022 - Study
Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors.
Citation Text:
Crannage AJ, Hennessey EK, Challen LM, et al. . Implementation of a discharge education program to improve transitions of care for patients …
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psnet.ahrq.gov/issue/implementation-mandatory-checklist-protocols-and-objectives-improves-compliance-wide-range
September 22, 2010 - Study
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.
Citation Text:
Byrnes MC, Schuerer DJE, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectiv…
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psnet.ahrq.gov/issue/irish-national-adverse-events-study-inaes-frequency-and-nature-adverse-events-irish-hospitals
March 03, 2021 - Study
The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study.
Citation Text:
Rafter N, Hickey A, Conroy RM, et al. The Irish National Adverse Events Study (INAES): the frequency and nature of adve…
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psnet.ahrq.gov/issue/reducing-risks-complex-care-transitions-rural-areas-grounded-theory
June 23, 2021 - Study
Reducing risks in complex care transitions in rural areas: a grounded theory.
Citation Text:
Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964. doi:10.1080/17482…
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psnet.ahrq.gov/issue/safely-practicing-new-environment-qualitative-study-inform-physician-onboarding-practices
July 02, 2019 - Study
Safely practicing in a new environment: a qualitative study to inform physician onboarding practices.
Citation Text:
Lagoo J, Berry WR, Henrich N, et al. Safely practicing in a new environment: a qualitative study to inform physician onboarding practices. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/electronic-health-record-related-safety-concerns-cross-sectional-survey
August 03, 2016 - Study
Electronic health record–related safety concerns: a cross-sectional survey.
Citation Text:
Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146.
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psnet.ahrq.gov/issue/understanding-how-rapid-response-systems-may-improve-safety-acutely-ill-patient-learning
July 08, 2015 - Study
Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline.
Citation Text:
Mackintosh N, Rainey H, Sandall J. Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the front…
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psnet.ahrq.gov/issue/epistemology-patient-safety-research-framework-study-design-and-interpretation
February 23, 2011 - Study
Classic
An epistemology of patient safety research: a framework for study design and interpretation.
Citation Text:
Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 4. One s…
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psnet.ahrq.gov/issue/types-and-effects-feedback-emergency-ambulance-staff-systematic-mixed-studies-review-and-meta
April 06, 2022 - Study
Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis.
Citation Text:
Wilson C, Janes G, Lawton R, et al. Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis. BMJ…
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psnet.ahrq.gov/issue/using-computerized-provider-order-entry-and-clinical-decision-support-improve-referring
August 20, 2018 - Study
Using computerized provider order entry and clinical decision support to improve referring physicians' implementation of consultants' medical recommendations.
Citation Text:
Were MC, Abernathy G, Hui SL, et al. Using computerized provider order entry and clinical decision support…
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psnet.ahrq.gov/issue/enhancing-patient-safety-and-quality-care-improving-usability-electronic-health-record
March 04, 2011 - Commentary
Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA.
Citation Text:
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electro…
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psnet.ahrq.gov/issue/integrating-computerized-clinical-decision-support-systems-clinical-work-meta-synthesis
October 19, 2022 - Review
Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.
Citation Text:
Miller A, Moon B, Anders S, et al. Integrating computerized clinical decision support systems into clinical work: A meta-synthesis of qualitative…
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - National Patient Safety Goals
March 27, 2024
Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/national-patient-safety-goals
Background
Despite the development and publication of effective and evidence-based strategies to enhance patient
safety and reduce preventable h…
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
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Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …