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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - August 10, 2022
Implementation of a standardized postanesthesia care handoff increases
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
March 01, 2023 - Making the referral at discharge increases the chances it will be discussed with the
patient prior to
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psnet.ahrq.gov/node/72795/psn-pdf
March 03, 2021 - Use of patient complaints to identify diagnosis-related
safety concerns: a mixed-method evaluation.
March 3, 2021
Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety
concerns: a mixed-method evaluation. BMJ Qual Saf. 2021;30(12):996-1001. doi:10.1136/bmjqs-2020-…
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - Improving Diagnosis in Health Care.
September 23, 2015
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine.
Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care
The National Academy of Me…
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psnet.ahrq.gov/node/73294/psn-pdf
January 01, 2022 - Understanding the second victim experience among
multidisciplinary providers in obstetrics and gynecology.
May 19, 2021
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. Understanding the second victim experience among
multidisciplinary providers in obstetrics and gynecology. J Patient Saf. 2022;18(2):e463-e469.
doi…
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psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
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psnet.ahrq.gov/node/857455/psn-pdf
January 01, 2024 - Addressing veteran health-related social needs: how
Joint Commission standards accelerated integration and
expansion of tools and services in the Veterans Health
Administration.
December 6, 2023
List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social needs: how Joint
Commission standard…
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psnet.ahrq.gov/node/867441/psn-pdf
January 08, 2025 - Consumer involvement in the design and development of
medication safety interventions or services in primary
care: a scoping review.
January 8, 2025
DelDot M, Lau E, Rayner N, et al. Consumer involvement in the design and development of medication
safety interventions or services in primary care: a scoping review.…
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psnet.ahrq.gov/node/73350/psn-pdf
June 02, 2021 - Learning during crisis: the impact of COVID-19 on
hospital-acquired pressure injury incidence.
June 2, 2021
Polancich S, Hall AG, Miltner RS, et al. Learning during crisis: the impact of COVID-19 on hospital-acquired
pressure injury incidence. J Healthc Qual. 2021;43(3):137-144. doi:10.1097/jhq.0000000000000301.
h…
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psnet.ahrq.gov/node/867594/psn-pdf
January 22, 2025 - A systematic review on the evidence of misdiagnosis in
dementia and its impact on accessing dementia care.
January 22, 2025
Giebel C, Silva?Ribeiro W, Watson J, et al. A systematic review on the evidence of misdiagnosis in
dementia and its impact on accessing dementia care. Int J Geriat Psychiatry. 2024;39(10):e615…
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psnet.ahrq.gov/node/47856/psn-pdf
June 02, 2019 - The impact of patient–physician alliance on trust
following an adverse event.
June 2, 2019
Shoemaker K, Smith CP. The impact of patient-physician alliance on trust following an adverse event.
Patient Educ Couns. 2019;102(7):1342-1349. doi:10.1016/j.pec.2019.02.015.
https://psnet.ahrq.gov/issue/impact-patient-physi…
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psnet.ahrq.gov/node/37241/psn-pdf
December 16, 2011 - The impact of safety organizing, trusted leadership, and
care pathways on reported medication errors in hospital
nursing units.
December 16, 2011
Vogus TJ, Sutcliffe K. The impact of safety organizing, trusted leadership, and care pathways on reported
medication errors in hospital nursing units. Med Care. 2007;45(…
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psnet.ahrq.gov/node/72820/psn-pdf
March 10, 2021 - Medication errors related to computerized provider order
entry systems in hospitals and how they change over
time: a narrative review.
March 10, 2021
Kinlay M, Zheng WY, Burke R, et al. Medication errors related to computerized provider order entry
systems in hospitals and how they change over time: A narrative re…
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psnet.ahrq.gov/node/60047/psn-pdf
March 18, 2020 - A systematic review exploring the content and outcomes
of interventions to improve psychological safety,
speaking up and voice behaviour.
March 18, 2020
O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to
improve psychological safety, speaking up and voice behaviour…
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psnet.ahrq.gov/node/73425/psn-pdf
June 23, 2021 - A qualitative study of what care workers do to provide
patient safety at home through telecare.
June 23, 2021
Stokke R, Melby L, Isaksen J, et al. A qualitative study of what care workers do to provide patient safety at
home through telecare. BMC Health Serv Res. 2021;21(1):553. doi:10.1186/s12913-021-06556-4.
htt…
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psnet.ahrq.gov/node/73188/psn-pdf
April 28, 2021 - Enhancing patient safety by integrating ethical
dimensions to critical incident reporting systems.
April 28, 2021
Wehkamp K, Kuhn E, Petzina R, et al. Enhancing patient safety by integrating ethical dimensions to Critical
Incident Reporting Systems. BMC Med Ethics. 2021;22(1):26. doi:10.1186/s12910-021-00593-8.
ht…
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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hcup-us.ahrq.gov/datainnovations/MNAbstractFinal.pdf
September 29, 2013 - Title:
State: Minnesota
Title: Using Clinically Enhanced Claims Data to Guide Treatment of
Acute Heart Failure
Principal Investigator: Mark Sonneborn
Organization: Minnesota Hospital Association
Project Dates: September 30, 2010, to September 29, 2013
Grant Number: R01 HS20043-01
The long-term objec…
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psnet.ahrq.gov/node/61044/psn-pdf
January 01, 2021 - Seven features of safety in maternity units: a framework
based on multisite ethnography and stakeholder
consultation.
October 21, 2020
Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in maternity units: a framework based on
multisite ethnography and stakeholder consultation. BMJ Qual Saf. 2021;3…
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psnet.ahrq.gov/node/866902/psn-pdf
October 09, 2024 - Why do acute healthcare staff behave unprofessionally
towards each other and how can these behaviours be
reduced? A realist review.
October 9, 2024
Aunger JA, Abrams R, Westbrook JI, et al. Why do acute healthcare staff behave unprofessionally towards
each other and how can these behaviours be reduced? A realist r…