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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/perspective/weekend-effect
April 01, 2008 - Annual Perspective
The Weekend Effect
Sumant Ranji, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Ranji SR. The Weekend Effect. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…
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psnet.ahrq.gov/node/845360/psn-pdf
March 29, 2023 - Demonstrating the value of a standardized cognitive
assessment tool through the use of interprofessional
rapid safety rounds.
March 29, 2023
Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment
tool through the use of interprofessional rapid safety rounds. J Nurs Car…
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psnet.ahrq.gov/node/43344/psn-pdf
July 16, 2014 - Cost-effectiveness of a computerized provider order entry
system in improving medication safety ambulatory care.
July 16, 2014
Forrester SH, Hepp Z, Roth JA, et al. Cost-Effectiveness of a Computerized Provider Order Entry System
in Improving Medication Safety Ambulatory Care. Value Health. 2014;17(4):340-349.
doi…
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psnet.ahrq.gov/node/47674/psn-pdf
December 19, 2018 - Patient safety after implementation of a coproduced
family centered communication programme: multicenter
before and after intervention study.
December 19, 2018
Khan A, Spector ND, Baird JD, et al. Patient safety after implementation of a coproduced family centered
communication programme: multicenter before and af…
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psnet.ahrq.gov/node/41451/psn-pdf
October 19, 2012 - Challenges of making a diagnosis in the outpatient
setting: a multi-site survey of primary care physicians.
October 19, 2012
Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-
site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648. doi:10.113…
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psnet.ahrq.gov/node/39526/psn-pdf
December 02, 2014 - Decrease in hospital-wide mortality rate after
implementation of a commercially sold computerized
physician order entry system.
December 2, 2014
Longhurst CA, Parast L, Sandborg CI, et al. Decrease in hospital-wide mortality rate after implementation
of a commercially sold computerized physician order entry system…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/39438/psn-pdf
March 23, 2011 - Time to listen: a review of methods to solicit patient
reports of adverse events.
March 23, 2011
King A, Daniels J, Lim J, et al. Time to listen: a review of methods to solicit patient reports of adverse
events. Qual Saf Health Care. 2010;19(2):148-57. doi:10.1136/qshc.2008.030114.
https://psnet.ahrq.gov/issue/tim…
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psnet.ahrq.gov/node/43817/psn-pdf
November 23, 2016 - Developing and evaluating the success of a family
activated medical emergency team: a quality
improvement report.
November 23, 2016
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical
emergency team: a quality improvement report. BMJ Qual Saf. 2015;24(3):203-211. …
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psnet.ahrq.gov/node/45033/psn-pdf
July 16, 2019 - A cross-sectional observational study of high override
rates of drug allergy alerts in inpatient and outpatient
settings, and opportunities for improvement.
July 16, 2019
Slight SP, Beeler PE, Seger DL, et al. A cross-sectional observational study of high override rates of drug
allergy alerts in inpatient and outp…
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psnet.ahrq.gov/node/46985/psn-pdf
July 02, 2019 - The impact of automated notification on follow-up of
actionable tests pending at discharge: a cluster-
randomized controlled trial.
July 2, 2019
Dalal A, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification on Follow-up of Actionable
Tests Pending at Discharge: a Cluster-Randomized Controlled Tria…
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psnet.ahrq.gov/node/43539/psn-pdf
March 26, 2015 - Challenges and remediation for Patient Safety Indicators
in the transition to ICD-10-CM.
March 26, 2015
Boyd AD, Yang YM, Li J, et al. Challenges and remediation for Patient Safety Indicators in the transition to
ICD-10-CM. J Am Med Inform Assoc. 2015;22(1):19-28. doi:10.1136/amiajnl-2013-002491.
https://psnet.ahr…
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psnet.ahrq.gov/node/46704/psn-pdf
December 04, 2018 - Surveying care teams after in-hospital deaths to identify
preventable harm and opportunities to improve advance
care planning.
December 4, 2018
Lucier D, Folcarelli P, Totte C, et al. Surveying Care Teams after in-Hospital Deaths to Identify Preventable
Harm and Opportunities to Improve Advance Care Planning. Jt C…
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psnet.ahrq.gov/node/43630/psn-pdf
April 15, 2016 - Evaluation of adverse drug events and medication
discrepancies in transitions of care between hospital
discharge and primary care follow-up.
April 15, 2016
Armor BL, Wight AJ, Carter SM. Evaluation of Adverse Drug Events and Medication Discrepancies in
Transitions of Care Between Hospital Discharge and Primary Car…
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psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
May 01, 2023 - Toolkit
Opioid deprescribing toolkit.
Citation Text:
Health Innovation East, National Health Service. Opioid deprescribing toolkit.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation
…
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psnet.ahrq.gov/node/43386/psn-pdf
January 20, 2016 - The influence of organizational factors on patient safety:
examining successful handoffs in health care.
January 20, 2016
Richter J, McAlearney AS, Pennell ML. The influence of organizational factors on patient safety: Examining
successful handoffs in health care. Health Care Manage Rev. 2016;41(1):32-41.
doi:10.1…
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psnet.ahrq.gov/node/42945/psn-pdf
February 19, 2014 - Integrating patient safety into health professionals'
curricula: a qualitative study of medical, nursing and
pharmacy faculty perspectives.
February 19, 2014
Tregunno D, Ginsburg LR, Clarke B, et al. Integrating patient safety into health professionals' curricula: a
qualitative study of medical, nursing and pharma…