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psnet.ahrq.gov/node/46856/psn-pdf
June 20, 2018 - Visual acuity, literacy, and unintentional misuse of
nonprescription medications.
June 20, 2018
Mullen RJ, Curtis LM, O'Conor R, et al. Visual acuity, literacy, and unintentional misuse of nonprescription
medications. Am J Health-Syst Pharm. 2018;75(9):e213-e220. doi:10.2146/ajhp170303.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45177/psn-pdf
June 01, 2016 - Quantifying the burden of opioid medication errors in
adult oncology and palliative care settings: a systematic
review.
June 1, 2016
Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology
and palliative care settings: A systematic review. Palliat Med. 2016;30(6):520…
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large health
system.
July 31, 2013
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global
trigger tool application across a large health system. Jt Comm J Qual Saf. 2013;39(…
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psnet.ahrq.gov/node/38628/psn-pdf
May 13, 2009 - Fast forward rounds: an effective method for teaching
medical students to transition patients safely across care
settings.
May 13, 2009
Ouchida K, LoFaso VM, Capello CF, et al. Fast forward rounds: an effective method for teaching medical
students to transition patients safely across care settings. J Am Geriatr So…
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psnet.ahrq.gov/node/43224/psn-pdf
June 11, 2014 - Look alike/sound alike drugs: a literature review on
causes and solutions.
June 11, 2014
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J
Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
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psnet.ahrq.gov/node/41031/psn-pdf
February 10, 2012 - Is patient safety improving? National trends in patient
safety indicators: 1998–2007.
February 10, 2012
Downey JR, Hernandez-Boussard T, Banka G, et al. Is patient safety improving? National trends in patient
safety indicators: 1998-2007. Health Serv Res. 2012;47(1 Pt 2):414-30. doi:10.1111/j.1475-
6773.2011.01361…
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - What is known about adverse events in older medical
hospital inpatients? A systematic review of the literature.
December 29, 2014
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital
inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…
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psnet.ahrq.gov/node/44635/psn-pdf
June 21, 2016 - Evaluation of perioperative medication errors and adverse
drug events.
June 21, 2016
Nanji KC, Patel A, Shaikh S, et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events.
Anesthesiology. 2016;124(1):25-34. doi:10.1097/ALN.0000000000000904.
https://psnet.ahrq.gov/issue/evaluation-perioperative-…
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psnet.ahrq.gov/node/38645/psn-pdf
February 15, 2011 - A comprehensive pharmacist intervention to reduce
morbidity in patients 80 years or older: a randomized
controlled trial.
February 15, 2011
Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in
patients 80 years or older: a randomized controlled trial. Arch Inter…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/7Rk5oKeK_cSwtrdnkHC7Vc
Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Clinical Summary of USPSTF Recommendation
BEHAVIORAL COUNSELING TO PROMOTE A HEALTHFUL DIET AND PHYSICAL ACTIVITY FOR CARDIOVASCULAR
DISEASE PREVENTION IN ADULT…
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digital.ahrq.gov/location/usa-mo-st-louis
January 01, 2023 - USA, MO, St. Louis
EnhanCed HandOffs (ECHO)
Description
This research will develop and evaluate a machine learning-augmented and telemedicine-augmented sociotechnical intervention for postoperative handoffs to reduce the risks of patient complications and improve patient-cen…
-
psnet.ahrq.gov/node/37940/psn-pdf
June 16, 2010 - Comparing patient-reported hospital adverse events with
medical record review: do patients know something that
hospitals do not?
June 16, 2010
Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with
medical record review: do patients know something that hospitals do n…
-
psnet.ahrq.gov/node/43915/psn-pdf
September 27, 2017 - The quality of hospital work environments and missed
nursing care is linked to heart failure readmissions: a
cross-sectional study of US hospitals.
September 27, 2017
Carthon MB, Lasater KB, Sloane DM, et al. The quality of hospital work environments and missed nursing
care is linked to heart failure readmissions:…
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psnet.ahrq.gov/node/41694/psn-pdf
September 19, 2012 - Effect of nonpayment for hospital-acquired,
catheter–associated urinary tract infection: a statewide
analysis.
September 19, 2012
Meddings JA, Reichert H, Rogers MAM, et al. Effect of nonpayment for hospital-acquired, catheter-
associated urinary tract infection: a statewide analysis. Ann Intern Med. 2012;157(5):3…
-
psnet.ahrq.gov/node/41568/psn-pdf
April 05, 2013 - Preventable deaths due to problems in care in English
acute hospitals: a retrospective case record review study.
April 5, 2013
Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals:
a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…
-
psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
-
psnet.ahrq.gov/node/48165/psn-pdf
August 28, 2019 - Competencies for improving diagnosis: an
interprofessional framework for education and training in
health care.
August 28, 2019
Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework
for education and training in health care. Diagnosis (Berl). 2019;6(4):335-341. doi…
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www.ahrq.gov/hai/cusp/toolkit/ceo-snr-leader-chcklst.html
December 01, 2012 - CEO and Senior Leader Checklist
CUSP Toolkit
Checklists for senior leadership
Who should use this tool? Senior leaders.
Checklist items
Leader Responsible
Date Initiated
1. Ensure all current and new employees receive Science of Safety training.
2. Assign a senior executive …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/ceosnrleaderchcklst.docx
June 02, 2025 - CEO/Senior Leader Checklist
Who should use this tool? Senior leaders.
Checklist Items
Leader Responsible
Date
Initiated
1. Ensure all current and new employees receive Science of Safety training.
2. Assign a senior executive (Chief Executive Officer or another leader) as an active member of each
-
psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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