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psnet.ahrq.gov/node/43446/psn-pdf
May 06, 2015 - A qualitative evaluation of the barriers and facilitators
toward implementation of the WHO surgical safety
checklist across hospitals in England: lessons from the
"Surgical Checklist Implementation Project."
May 6, 2015
Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitator…
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psnet.ahrq.gov/node/840139/psn-pdf
November 16, 2022 - CDC Clinical Practice Guideline for Prescribing Opioids
for Pain - United States, 2022.
November 16, 2022
Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain —
United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41999/psn-pdf
January 01, 2016 - Maintaining and sustaining the On the CUSP: Stop BSI
model in Hawaii.
January 30, 2013
Lin D, Weeks K, Holzmueller CG, et al. Maintaining and Sustaining the On the CUSP: Stop BSI Model in
Hawaii. Jt Comm J Qual Patient Saf. 2016;39(2):51-60, AP3. doi:10.1016/s1553-7250(13)39008-4.
https://psnet.ahrq.gov/issue/main…
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psnet.ahrq.gov/node/850342/psn-pdf
June 14, 2023 - Eliminating central line associated bloodstream infections
in pediatric oncology patients: a quality improvement
effort.
June 14, 2023
Willis DN, Looper K, Malone RA, et al. Eliminating central line associated bloodstream infections in
pediatric oncology patients: a quality improvement effort. Pediatr Qual Saf. 20…
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psnet.ahrq.gov/node/61099/psn-pdf
November 04, 2020 - Twelve-month review of infusion pump near-miss
medication and dose selection errors and user-initiated
"good save" corrections: retrospective study.
November 4, 2020
Waterson J, Al-Jaber R, Kassab T, et al. Twelve-month review of infusion pump near-miss medication and
dose selection errors and user-Initiated "good…
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psnet.ahrq.gov/node/38205/psn-pdf
November 12, 2008 - Characteristics of medication errors and adverse drug
events in hospitals participating in the California Pediatric
Patient Safety Initiative.
November 12, 2008
Takata GS, Taketomo CK, Waite S, et al. Characteristics of medication errors and adverse drug events in
hospitals participating in the California Pediatri…
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psnet.ahrq.gov/node/866646/psn-pdf
September 04, 2024 - Adverse events and perceived abandonment: learning
from patients' accounts of medical mishaps.
September 4, 2024
Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from
patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. doi:10.1136/bmjoq-2024-
002848…
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psnet.ahrq.gov/node/73374/psn-pdf
June 09, 2021 - Effects of pharmacist-conducted medication
reconciliation at discharge on 30-day readmission rates of
patients with chronic obstructive pulmonary disease.
June 9, 2021
Singh D, Fahim G, Ghin HL, et al. Effects of pharmacist-conducted medication reconciliation at discharge
on 30-day readmission rates of patients wi…
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psnet.ahrq.gov/node/42178/psn-pdf
April 10, 2013 - Outside case review of surgical pathology for referred
patients: the impact on patient care.
April 10, 2013
Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients:
the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA.
htt…
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psnet.ahrq.gov/node/43101/psn-pdf
May 30, 2014 - Instituting a culture of professionalism: the establishment
of a Center for Professionalism and Peer Support.
May 30, 2014
Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for
professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
…
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psnet.ahrq.gov/node/842764/psn-pdf
January 18, 2023 - Medication use evaluation of high-dose long-term opioid
de-prescribing in multiple Veterans Affairs medical
centers.
January 18, 2023
Barrett AK, Sandbrink F, Mardian A, et al. Medication use evaluation of high-dose long-term opioid de-
prescribing in multiple Veterans Affairs medical centers. J Gen Intern Med. 20…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/issue/prospects-comparing-european-hospitals-terms-quality-and-safety-lessons-comparative-study
February 20, 2019 - Study
Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries.
Citation Text:
Burnett S, Renz A, Wiig S, et al. Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative st…
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psnet.ahrq.gov/issue/characteristics-medication-errors-and-adverse-drug-events-hospitals-participating-california
July 13, 2010 - Study
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Citation Text:
Takata GS, Taketomo CK, Waite S, et al. Characteristics of medication errors and adverse drug events in hospitals particip…
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psnet.ahrq.gov/issue/safe-patient-flow-initiative-collaborative-quality-improvement-journey-yale-new-haven
June 07, 2023 - Study
The Safe Patient Flow Initiative: a collaborative quality improvement journey at Yale-New Haven Hospital.
Citation Text:
Jweinat J, Damore P, Morris V, et al. The safe patient flow initiative: a collaborative quality improvement journey at Yale-New Haven Hospital. Jt Comm J Q…
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psnet.ahrq.gov/issue/flight-deck-operating-room-initial-pilot-study-feasibility-and-potential-impact-true
February 25, 2009 - Study
From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.
Citation Text:
Paige JT, Kozmenko V, Morgan B, et al. From the Flight Deck to the Operating Room: A…
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psnet.ahrq.gov/issue/physician-engagement-organisational-patient-safety-through-implementation-medical-safety
February 22, 2011 - Study
Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.
Citation Text:
Rotteau L, Othman D, Dunbar-Yaffe R, et al. Physician engagement in organisational patient safety through the implementation o…
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psnet.ahrq.gov/issue/prescription-long-acting-opioids-and-mortality-patients-chronic-noncancer-pain
August 08, 2018 - Study
Prescription of long-acting opioids and mortality in patients with chronic noncancer pain.
Citation Text:
Ray WA, Chung CP, Murray KT, et al. Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. JAMA. 2016;315(22):2415-23. doi:10.1001/jama.2016…
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psnet.ahrq.gov/issue/multicomponent-pharmacist-intervention-did-not-reduce-clinically-important-medication-errors
March 17, 2021 - Study
Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.
Citation Text:
Kapoor A, Patel P, Mbusa D, et al. Multicomponent pharmacist intervention did not reduce clinically important m…
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psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers-seniors
May 04, 2010 - Study
Inadequate health literacy among paid caregivers of seniors.
Citation Text:
Lindquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-9. doi:10.1007/s11606-010-1596-2.
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