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psnet.ahrq.gov/issue/analysis-readmissions-mobile-integrated-health-transitional-care-program-using-root-cause
June 08, 2022 - Study
Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.
Citation Text:
Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional care program using root …
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psnet.ahrq.gov/issue/error-reduction-pediatric-chemotherapy-computerized-order-entry-and-failure-modes-and-effects
August 02, 2010 - Study
Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.
Citation Text:
Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Ad…
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psnet.ahrq.gov/issue/changes-safety-attitude-and-relationship-decreased-postoperative-morbidity-and-mortality
May 27, 2010 - Study
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
Citation Text:
Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decrease…
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psnet.ahrq.gov/issue/vulnerabilities-computerized-physician-order-entry-systems-qualitative-study
July 02, 2019 - Study
The vulnerabilities of computerized physician order entry systems: a qualitative study.
Citation Text:
Slight SP, Eguale T, Amato MG, et al. The vulnerabilities of computerized physician order entry systems: a qualitative study: Table 1. J Am Med Inform Assoc. 2015;23(2):311-316. d…
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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/issue/self-reported-medical-medication-and-laboratory-error-eight-countries-risk-factors
September 19, 2012 - Study
Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.
Citation Text:
Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Int J Qual Health Care. 2…
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psnet.ahrq.gov/issue/water-cooler-learning-knowledge-sharing-clinical-backstage-and-its-contribution-patient
January 29, 2014 - Study
"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety.
Citation Text:
Waring J, Bishop S. "Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety. J Health Organ Manag. 2…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Security Lapse
September 1, 2004
Mason D. Security Lapse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/security-lapse
The Case
A medical student learned that the hospital's radiology image library was accessible throughout the
university's computer system, meaning that patient x-rays could be viewed in d…
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psnet.ahrq.gov/node/49647/psn-pdf
February 01, 2012 - Amended Lab Results: Communication Slip
February 1, 2012
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
The Case
A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension
an…
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psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network
Robert M. Wachter, MD | November 1, 2015
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Update: Patient Engagement in Safety
January 1, 2018
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/update-patient-engagement-safety
Annual Perspective 2018
Background
Patient engagement has become a cornerstone of patient safety. A Patient Saf…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
…
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Safety In Dentistry
Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ramoni R, Walji MF, Kalenderian E. Safety In De…
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Patient and Family Roles in Safety
Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD
| June 14, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Johnson B, Lee M, Mossburg S. Patient and Fam…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm
Beverley H. Johnson, FAAN
| June 14, 2023
Also Read the Essay
View more articles from the same authors.
Citation Text:
Johnson B. In Conversation with.. Beverley H…