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psnet.ahrq.gov/issue/impact-inpatient-electronic-prescribing-system-prescribing-error-causation-qualitative
February 16, 2022 - Study
Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital.
Citation Text:
Puaar SJ, Franklin BD. Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation …
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psnet.ahrq.gov/issue/identification-hospital-complications-claims-data-it-valid
June 13, 2011 - Study
Classic
Identification of in-hospital complications from claims data. Is it valid?
Citation Text:
Lawthers AG, McCarthy EP, Davis RB, et al. Identification of in-hospital complications from claims data. Is it valid? Med Care. 2000;38(8):785-95.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/sopstipsheet.pdf
June 02, 2025 - Tip Sheet: Improving Response Rates on the AHRQ Surveys on Patient Safety Culture
Tip Sheet: Improving Response Rates
on the AHRQ Surveys on Patient Safety Culture
This Tip Sheet will help you understand the importance of high survey response rates and provide suggestions for
improving your response rates.…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/briefing_debriefing.docx
December 01, 2017 - Tool: Briefing and Debriefing Tool
Briefing and Debriefing Tool
Introduction
Problem Statement
Surgical site infection (SSI) prevention remains a global public health priority. Patients in acute care hospitals underwent more than 16 million surgical procedures in the United States in 2010.1 Using National Healthcare S…
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/briefing-debriefing.html
December 01, 2017 - Briefing and Debriefing Tool
AHRQ Safety Program for Surgery
Introduction
Problem Statement
Surgical site infection (SSI) prevention remains a global public health priority. Patients in acute care hospitals underwent more than 16 million surgical procedures in the United States in 2010. 1 Usi…
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psnet.ahrq.gov/issue/weekend-effect-pediatric-surgery-increased-mortality-children-undergoing-urgent-surgery
February 01, 2012 - Study
Classic
The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend.
Citation Text:
Goldstein SD, Papandria DJ, Aboagye J, et al. The "weekend effect" in pediatric surgery - increased mortality fo…
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psnet.ahrq.gov/issue/defining-identifying-and-addressing-problematic-polypharmacy-within-multimorbidity-primary
July 22, 2015 - Review
Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review.
Citation Text:
Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scop…
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psnet.ahrq.gov/issue/principles-conservative-prescribing
April 22, 2017 - Review
Classic
Principles of conservative prescribing.
Citation Text:
Schiff G, Galanter W, Duhig J, et al. Principles of conservative prescribing. Arch Intern Med. 2011;171(16):1433-1440. doi:10.1001/archinternmed.2011.256.
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psnet.ahrq.gov/issue/effect-structured-medication-review-followed-face-face-feedback-prescribers-adverse-drug
January 18, 2013 - Study
The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.
Citation Text:
Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…
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psnet.ahrq.gov/issue/computerized-dose-range-checking-using-hard-and-soft-stop-alerts-reduces-prescribing-errors
June 16, 2010 - Study
Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.
Citation Text:
Balasuriya L, Vyles D, Bakerman P, et al. Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a …
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psnet.ahrq.gov/issue/evaluating-alert-fatigue-over-time-ehr-based-clinical-trial-alerts-findings-randomized
April 29, 2018 - Study
Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study.
Citation Text:
Embi P, Leonard AC. Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. J Am Med Inform…
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psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
October 07, 2020 - Study
Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.
Citation Text:
Harper A, Kukielka E, Jones RM. Patient harm resulting from medication reconciliation process failures: a study of serious events rep…
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www.ahrq.gov/sops/about/patient-safety-culture.html
June 01, 2024 - What Is Patient Safety Culture?
Patient Safety Culture Defined Patient safety culture is the extent to which an organization's culture supports and promotes patient safety. It refers to the values, beliefs, and norms that are shared by healthcare practitioners and other staff throughout the organization that in…
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psnet.ahrq.gov/issue/sustaining-reliability-accountability-measures-johns-hopkins-hospital
January 19, 2014 - Study
Sustaining reliability on accountability measures at the Johns Hopkins Hospital.
Citation Text:
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
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digital.ahrq.gov/ahrq-funded-projects/secure-messaging-pediatric-respiratory-medicine-setting
January 01, 2023 - Secure Messaging in a Pediatric Respiratory Medicine Setting
Project Final Report ( PDF , 1.14 MB)
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Annual Summaries
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psnet.ahrq.gov/issue/international-perspective-definitions-and-terminology-used-describe-serious-reportable
August 04, 2021 - Review
An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review.
Citation Text:
Hegarty J, Flaherty SJ, Saab MM, et al. An international perspective on definitions and terminology used to describe seri…
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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-practice-redesign-impact-health-information-technology-on-workflow-ma
January 01, 2023 - Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow
Project Final Report ( PDF , 3.82 MB)
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Project Description
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…
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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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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/bonnevie-l-et-al-2005
January 01, 2005 - Bonnevie L et al. 2005 "The use of computerized decision support systems in preventive cardiology-principal results from the national PRECARD survey in Denmark."
Reference
Bonnevie L, Thomsen T, Jorgensen T. The use of computerized decision support systems in preventive cardiology-principal results fr…
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psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events-children-and
March 24, 2021 - Study
National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.
Citation Text:
Cohen AL, Budnitz DS, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events in children and …