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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - popular press (1), and
may result in substantial complications and death.(2) Unfortunately, their true incidence
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - For example, if a hospital identifies an elevated incidence of postoperative sepsis (PSI 13), it may
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - February 7, 2024
Risk reduction strategy to decrease incidence of retained surgical items
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psnet.ahrq.gov/issue/medsafer-study-electronic-decision-support-deprescribing-hospitalized-older-adults-cluster
July 31, 2019 - Study
The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.
Citation Text:
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a …
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psnet.ahrq.gov/issue/make-or-buy-patient-safety-solutions-resource-dependence-and-transaction-cost-economics
April 08, 2008 - Study
To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.
Citation Text:
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective. Health Care Manage Rev. 2011;36(…
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psnet.ahrq.gov/issue/association-between-workarounds-and-medication-administration-errors-bar-code-assisted
August 26, 2020 - Study
Classic
Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.
Citation Text:
van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process.
Citation Text:
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…
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psnet.ahrq.gov/issue/validity-unplanned-admission-intensive-care-unit-measure-patient-safety-surgical-patients
May 26, 2021 - Study
Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.
Citation Text:
Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthe…
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psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data
March 15, 2017 - Study
Missed diagnosis of cancer in primary care: insights from malpractice claims data.
Citation Text:
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.…
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psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and-categorise
February 15, 2023 - Study
Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.
Citation Text:
Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: devel…
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psnet.ahrq.gov/issue/road-map-advancing-practice-respect-health-care-results-interdisciplinary-modified-delphi
August 01, 2018 - Study
A road map for advancing the practice of respect in health care: the results of an interdisciplinary modified Delphi consensus study.
Citation Text:
Sokol-Hessner L, Folcarelli P, Annas CL, et al. A Road Map for Advancing the Practice of Respect in Health Care: The Results of an In…
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psnet.ahrq.gov/issue/outcomes-and-patient-safety-overlapping-vs-nonoverlapping-total-joint-arthroplasty-systematic
February 02, 2022 - Review
Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis.
Citation Text:
Malahias M-A, Antoniadou T, Jang SJ, et al. Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a syste…
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psnet.ahrq.gov/issue/comparing-patient-reported-hospital-adverse-events-medical-record-review-do-patients-know
February 03, 2011 - Study
Classic
Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?
Citation Text:
Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with…
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psnet.ahrq.gov/issue/prevalence-patterns-and-predictors-nursing-care-left-undone-european-hospitals-results
January 04, 2015 - Study
Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.
Citation Text:
Ausserhofer D, Zander B, Busse R, et al. Prevalence, patterns and predictors of nursing care left undone in European h…
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psnet.ahrq.gov/issue/strategies-prevent-missed-nursing-care-international-qualitative-study-based-upon-positive
May 18, 2022 - Study
Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.
Citation Text:
Longhini J, Papastavrou E, Efstathiou G, et al. Strategies to prevent missed nursing care: an international qualitative study based upon a positive …
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psnet.ahrq.gov/issue/we-want-know-mixed-methods-evaluation-comprehensive-program-designed-detect-and-address
October 17, 2018 - Study
We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.
Citation Text:
Fisher KA, Smith KM, Gallagher TH, et al. We Want to Know-a mixed methods evaluation of a comprehensive program designed to detec…
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psnet.ahrq.gov/issue/medicare-and-medicaid-programs-and-childrens-health-insurance-program-hospital-inpatient
November 23, 2015 - Legislation/Regulation
Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requir…
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psnet.ahrq.gov/issue/global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously
February 15, 2011 - Study
Classic
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Citation Text:
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times grea…
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psnet.ahrq.gov/issue/use-computerized-physician-order-entry-clinical-decision-support-prevent-dose-errors
June 05, 2024 - Review
Use of computerized physician order entry with clinical decision support to prevent dose errors in pediatric medication orders: a systematic review.
Citation Text:
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical decision suppo…