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psnet.ahrq.gov/node/41635/psn-pdf
January 18, 2013 - Improvement in the detection of adverse drug events by
the use of electronic health and prescription records: an
evaluation of two trigger tools.
January 18, 2013
Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by
the use of electronic health and prescription reco…
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psnet.ahrq.gov/node/50893/psn-pdf
February 12, 2020 - The Rural VA Multi-Center Medication Reconciliation
Quality Improvement Study (R-VA-MARQUIS).
February 12, 2020
Presley CA, Wooldridge KT, Byerly SH, et al. The Rural VA Multi-Center Medication Reconciliation Quality
Improvement Study (R-VA-MARQUIS). Am J Health Syst Pharm. 2020;77(2):128-137.
doi:10.1093/ajhp/zxz…
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psnet.ahrq.gov/node/867757/psn-pdf
March 12, 2025 - Improving medication-related safety for residents in
nursing homes: a qualitative study.
March 12, 2025
Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a
qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-20250102-03.
https://psnet.ahrq.g…
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psnet.ahrq.gov/issue/comprehensive-patient-safety-program-can-significantly-reduce-preventable-harm-associated
October 27, 2010 - Study
A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.
Citation Text:
Brilli RJ, McClead RE, Crandall W, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs,…
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psnet.ahrq.gov/issue/tools-establishing-sustainable-safety-culture-within-maternity-services-retrospective-case
February 28, 2024 - Study
Tools for establishing a sustainable safety culture within maternity services: a retrospective case study.
Citation Text:
Løland M, Braut GS, Lichtenberg SM, et al. Tools for establishing a sustainable safety culture within maternity services: a retrospective case study. SAGE Open …
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psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-obstetrics-and-gynecology
April 05, 2017 - Study
Cause and effect analysis of closed claims in obstetrics and gynecology.
Citation Text:
White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038.
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psnet.ahrq.gov/issue/mortality-and-morbidity-meetings-untapped-resource-improving-governance-patient-safety
June 25, 2014 - Study
Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?
Citation Text:
Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf. 2012;21(7):…
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psnet.ahrq.gov/issue/management-deteriorating-adult-patient-does-simulation-based-education-improve-patient-safety
June 08, 2022 - Review
Management of the deteriorating adult patient: does simulation-based education improve patient safety?
Citation Text:
Bennion J, Mansell SK. Management of the deteriorating adult patient: does simulation-based education improve patient safety? Br J Hosp Med (Lond). 2021;82(8):1-8.…
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psnet.ahrq.gov/issue/opportunities-improve-diagnosis-emergency-transfers-pediatric-intensive-care-unit
June 28, 2023 - Study
Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.
Citation Text:
Mehta SD, Congdon M, Phillips CA, et al. Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit. J Hosp Med. 2023;18(6):509-518. do…
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psnet.ahrq.gov/issue/novel-method-reproducibly-measuring-effects-interventions-improve-emotional-climate-indices
March 16, 2011 - Study
A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.
Citation Text:
Nurok M, Lipsitz S, Satwicz P, et al. A novel me…
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psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness
January 29, 2014 - Study
Huddling for high reliability and situation awareness.
Citation Text:
Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467.
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psnet.ahrq.gov/issue/safer-delivery-surgical-services-program-s3-explaining-its-differential-effectiveness-and
January 20, 2015 - Study
The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.
Citation Text:
Flynn LC, McCulloch P, Morgan LJ, et al. The Safer Delivery of Surgical Services Program (S3): Explain…
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psnet.ahrq.gov/issue/improving-resident-physician-participation-reporting-patient-safety-and-quality-concerns
May 18, 2022 - Study
Improving resident physician participation in reporting patient safety and quality concerns.
Citation Text:
Craig SR, Smith HL, Shaeffer PJ. Improving resident physician participation in reporting patient safety and quality concerns. Ochsner J. 2024;24(2):118-123. doi:10.31486/toj.…
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psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
February 23, 2019 - Study
Classic
The business case for quality: case studies and an analysis.
Citation Text:
Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis. Health Aff (Millwood). 2003;22(2):17-30.
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psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
July 28, 2021 - Commentary
The Child Health PSO at 10 years: an emerging learning network.
Citation Text:
Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network. Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449.
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psnet.ahrq.gov/issue/shape-matters-neglected-feature-medication-safety-why-regulating-shape-medication-containers
December 09, 2020 - Commentary
Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety.
Citation Text:
Bitan Y, Nunnally M. Shape matters: a neglected feature of medication safety: why regulating the shape of medication contain…
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psnet.ahrq.gov/issue/improved-pain-resolution-hospitalized-patients-through-targeting-pain-mismanagement-medical
March 24, 2019 - Study
Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.
Citation Text:
Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage.…
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psnet.ahrq.gov/issue/effects-efforts-optimise-morbidity-and-mortality-rounds-serve-contemporary-quality
July 19, 2019 - Review
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Citation Text:
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to serve contem…
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psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
February 07, 2024 - Study
What can safety cases offer for patient safety? A multisite case study.
Citation Text:
Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042.
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psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-need-improve-measurement
November 03, 2015 - Commentary
Classic
Toward a safer health care system: the critical need to improve measurement.
Citation Text:
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement. JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448…