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psnet.ahrq.gov/node/38961/psn-pdf
September 01, 2016 - An empirical model to estimate the potential impact of
medication safety alerts on patient safety, health care
utilization, and cost in ambulatory care.
September 1, 2016
Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of
medication safety alerts on patient safety,…
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psnet.ahrq.gov/node/44197/psn-pdf
November 03, 2015 - Effect of the World Health Organization checklist on
patient outcomes: a stepped wedge cluster randomized
controlled trial.
November 3, 2015
Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization checklist on patient
outcomes: a stepped wedge cluster randomized controlled trial. Ann Su…
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psnet.ahrq.gov/node/44881/psn-pdf
August 16, 2017 - A comparative effectiveness analysis of the
implementation of surgical safety checklists in a tertiary
care hospital.
August 16, 2017
Bock M, Fanolla A, Segur-Cabanac I, et al. A Comparative Effectiveness Analysis of the Implementation of
Surgical Safety Checklists in a Tertiary Care Hospital. JAMA Surg. 2016;151(…
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psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - Complication rates, hospital size, and bias in the CMS
Hospital-Acquired Condition Reduction Program.
December 19, 2017
Koenig L, Soltoff SA, Demiralp B, et al. Complication Rates, Hospital Size, and Bias in the CMS Hospital-
Acquired Condition Reduction Program. Am J Med Qual. 2017;32(6):611-616.
doi:10.1177/1062…
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psnet.ahrq.gov/node/43690/psn-pdf
March 26, 2015 - Improving healthcare systems' disclosures of large-scale
adverse events: a Department of Veterans Affairs
leadership, policymaker, research and stakeholder
partnership.
March 26, 2015
Elwy R, Bokhour BG, Maguire EM, et al. Improving healthcare systems' disclosures of large-scale adverse
events: a Department of Ve…
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psnet.ahrq.gov/node/38816/psn-pdf
July 29, 2009 - Uncovering system errors using a rapid response team:
cross-coverage caught in the crossfire.
July 29, 2009
Kaplan LJ, Maerz LL, Schuster KM, et al. Uncovering System Errors Using a Rapid Response Team:
Cross-Coverage Caught in the Crossfire. The Journal of Trauma: Injury, Infection, and Critical Care.
2009;67(1).…
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psnet.ahrq.gov/node/40601/psn-pdf
September 29, 2017 - A policy-based intervention for the reduction of
communication breakdowns in inpatient surgical care:
results from a Harvard surgical safety collaborative.
September 29, 2017
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of
communication breakdowns in inpatient surg…
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psnet.ahrq.gov/node/41212/psn-pdf
March 14, 2012 - A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complaints and
chart review of inpatient deaths.
March 14, 2012
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complain…
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psnet.ahrq.gov/node/47189/psn-pdf
August 17, 2018 - Association of opioid-related adverse drug events with
clinical and cost outcomes among surgical patients in a
large integrated health care delivery system.
August 17, 2018
Shafi S, Collinsworth AW, Copeland LA, et al. Association of Opioid-Related Adverse Drug Events With
Clinical and Cost Outcomes Among Surgical…
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psnet.ahrq.gov/node/46299/psn-pdf
September 13, 2017 - Simulation-based assessment of the management of
critical events by board-certified anesthesiologists.
September 13, 2017
Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical
events by board-certified anesthesiologists. Anesthesiology. 2017;127(3):475-489.
doi:10.1097…
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psnet.ahrq.gov/node/44471/psn-pdf
September 27, 2016 - Two sides of the safety coin?: how patient engagement
and safety climate jointly affect error occurrence in
hospital units.
September 27, 2016
Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety
climate jointly affect error occurrence in hospital units. Health Care …
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psnet.ahrq.gov/node/42361/psn-pdf
September 19, 2013 - Involvement of patients with cancer in patient safety: a
qualitative study of current practices, potentials and
barriers.
September 19, 2013
Martin HM, Navne LE, Lipczak H. Involvement of patients with cancer in patient safety: a qualitative study
of current practices, potentials and barriers. BMJ Qual Saf. 2013;2…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - Falls have big consequences, especially in older adults, and we need to take the initiative to prevent … Another example is the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative ,
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - Another example is the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative , … Falls have big consequences, especially in older adults, and we need to take the initiative to prevent
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - RADAR: a closed-loop quality improvement initiative leveraging a safety net model for incidental pulmonary
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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psnet.ahrq.gov/web-mm/making-do
September 05, 2018 - Making Do
Citation Text:
Bradley LD. Making Do. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downloa…