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psnet.ahrq.gov/issue/nurses-and-patients-appraisals-show-patient-safety-hospitals-remains-concern
October 16, 2012 - Study
Emerging Classic
Nurses' and patients' appraisals show patient safety in hospitals remains a concern.
Citation Text:
Aiken LH, Sloane DM, Barnes H, et al. Nurses' And Patients' Appraisals Show Patient Safety In Hospitals Remains A Concern. Health Aff (Mill…
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psnet.ahrq.gov/issue/surgical-specimen-management-descriptive-study-648-adverse-events-and-near-misses
December 22, 2021 - Study
Surgical specimen management: a descriptive study of 648 adverse events and near misses.
Citation Text:
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396…
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psnet.ahrq.gov/issue/electronic-health-records-communication-and-data-sharing-challenges-and-opportunities
October 13, 2018 - Study
Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process.
Citation Text:
Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving t…
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psnet.ahrq.gov/issue/associations-between-stopping-prescriptions-opioids-length-opioid-treatment-and-overdose-or
April 05, 2017 - Study
Classic
Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation.
Citation Text:
Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescrip…
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psnet.ahrq.gov/issue/examining-validity-ahrqs-patient-safety-indicators-psis-variation-psi-composite-score-related
November 10, 2010 - Study
Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?
Citation Text:
Shin MH, Sullivan JL, Rosen AK, et al. Examining the validity of AHRQ's patient safety indicators (PSIs): is variation i…
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psnet.ahrq.gov/issue/estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters
December 30, 2014 - Commentary
Estimating deaths due to medical error: the ongoing controversy and why it matters.
Citation Text:
Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Qual Saf. 2017;26(5):423-428. doi:10.1136/bmjqs-2016-006144.
…
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psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
June 08, 2022 - Study
Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.
Citation Text:
Smits M, Langelaan M, de Groot J, et al. Examining causes and prevention strategies of adverse events in deceas…
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psnet.ahrq.gov/issue/safety-culture-operating-room-variability-among-perioperative-healthcare-workers
November 17, 2021 - Study
Safety culture in the operating room: variability among perioperative healthcare workers.
Citation Text:
Pimentel MPT, Choi S, Fiumara K, et al. Safety culture in the operating room: variability among perioperative healthcare workers. J Patient Saf. 2021;17(6):412-416. doi:10.1097/…
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psnet.ahrq.gov/issue/systematic-review-nurses-safety-attitudes-and-their-impact-patient-outcomes-acute-care
December 16, 2020 - Review
Systematic review: nurses' safety attitudes and their impact on patient outcomes in acute-care hospitals.
Citation Text:
Alanazi FK, Sim J, Lapkin S. Systematic review: nurses' safety attitudes and their impact on patient outcomes in acute-care hospitals. Nurs Open. 2022;9(1):30-4…
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psnet.ahrq.gov/issue/implementing-computerized-provider-order-entry-acute-care-hospitals-united-states-could
March 30, 2022 - Study
Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society.
Citation Text:
Nuckols TK, Asch SM, Patel V, et al. Implementing Computerized Provider Order Entry in Acute Care Hospitals in the United States…
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psnet.ahrq.gov/issue/electronic-approaches-making-sense-text-adverse-event-reporting-system
August 03, 2022 - Study
Electronic approaches to making sense of the text in the adverse event reporting system.
Citation Text:
Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event reporting system. J Healthc Risk Manag. 2016;36(2):10-20. doi:10.1002/jhr…
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psnet.ahrq.gov/issue/prescription-errors-and-outcomes-related-inconsistent-information-transmitted-through
April 04, 2011 - Study
Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.
Citation Text:
Singh H, Mani S, Espadas D, et al. Prescription errors and outcomes related to inconsistent information transmitted through compu…
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psnet.ahrq.gov/issue/visitor-behaviors-can-influence-risk-patient-harm-analysis-patient-safety-reports-92
September 01, 2021 - Study
Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals.
Citation Text:
Sanchez C, Taylor M, Jones RM. Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. Patien…
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psnet.ahrq.gov/issue/interactive-questioning-critical-care-during-handovers-transcript-analysis-communication
August 11, 2021 - Study
Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.
Citation Text:
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a tra…
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psnet.ahrq.gov/node/38704/psn-pdf
July 31, 2012 - Clinical Handover: Critical Communications.
July 31, 2012
Med J Aust. 2009;190(s11):s108-s157.
https://psnet.ahrq.gov/issue/clinical-handover-critical-communications
This supplement discusses Australian efforts to improve handover safety with emphasis on flexible
standardization, communication improvement, and inf…
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psnet.ahrq.gov/node/33609/psn-pdf
March 15, 2025 - Clinical Decision Support Systems
March 15, 2025
Clinical Decision Support Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/clinical-decision-support-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/node/36399/psn-pdf
May 04, 2015 - Tips for Safer Surgery.
May 4, 2015
Surgical Care Improvement Project. Oklahoma City, OK: Oklahoma Foundation for Medical Quality;
2006.
https://psnet.ahrq.gov/issue/tips-safer-surgery
This tip sheet provides a list of questions consumers should ask clinicians to help improve the safety of
their surgical car…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II
Frameworks
December 14, 2022
Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
Resilient healthca…
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psnet.ahrq.gov/node/36336/psn-pdf
October 26, 2010 - Interprofessional Approaches to Patient Safety.
October 26, 2010
J Interprof Care. 2006;20(5):461-563.
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
This issue includes articles that explore successful multidisciplinary efforts to improve patient safety,
including medication risk assessm…