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psnet.ahrq.gov/issue/improving-patient-safety-icu-prospective-identification-missing-safety-barriers-using-bow-tie
February 14, 2024 - Study
Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.
Citation Text:
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification o…
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psnet.ahrq.gov/issue/evaluation-harm-associated-high-dose-range-clinical-decision-support-overrides-intensive-care
August 17, 2018 - Study
Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.
Citation Text:
Wong A, Rehr C, Seger DL, et al. Evaluation of Harm Associated with High Dose-Range Clinical Decision Support Overrides in the Intensive Care Unit. Drug…
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psnet.ahrq.gov/issue/evaluation-medication-related-clinical-decision-support-alert-overrides-intensive-care-unit
July 02, 2019 - Study
Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.
Citation Text:
Wong A, Amato MG, Seger DL, et al. Evaluation of medication-related clinical decision support alert overrides in the intensive care unit. J Crit Care. 2017;39:156-1…
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psnet.ahrq.gov/issue/addition-electronic-prescription-transmission-computerized-prescriber-order-entry-effect
March 13, 2019 - Study
Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.
Citation Text:
Moniz TT, Seger AC, Keohane CA, et al. Addition of electronic prescription transmission to computerized prescriber order en…
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psnet.ahrq.gov/issue/accuracy-computer-generated-spanish-language-medicine-labels
March 01, 2023 - Study
Accuracy of computer-generated, Spanish-language medicine labels.
Citation Text:
Sharif I, Tse J. Accuracy of computer-generated, spanish-language medicine labels. Pediatrics. 2010;125(5):960-5. doi:10.1542/peds.2009-2530.
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psnet.ahrq.gov/issue/improving-communication-primary-care-physicians-time-hospital-discharge
November 16, 2022 - Study
Improving communication with primary care physicians at the time of hospital discharge.
Citation Text:
Destino LA, Dixit A, Pantaleoni JL, et al. Improving Communication with Primary Care Physicians at the Time of Hospital Discharge. Jt Comm J Qual Patient Saf. 2017;43(2):80-88. do…
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psnet.ahrq.gov/issue/unplanned-transfers-medical-intensive-care-unit-causes-and-relationship-preventable-errors
July 19, 2023 - Study
Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.
Citation Text:
Bapoje SR, Gaudiani JL, Narayanan V, et al. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J …
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psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught-crossfire
April 24, 2018 - Study
Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
Citation Text:
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, Infect…
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psnet.ahrq.gov/issue/physician-antipsychotic-overprescribing-letters-and-cognitive-behavioral-and-physical-health
March 05, 2025 - Study
Physician antipsychotic overprescribing letters and cognitive, behavioral, and physical health outcomes among people with dementia: a secondary analysis of a randomized clinical trial.
Citation Text:
Harnisch M, Barnett ML, Coussens S, et al. Physician antipsychotic overprescribing…
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psnet.ahrq.gov/issue/i-think-medicine-actually-killed-my-wife-patient-and-family-perspectives-shared-decision
October 05, 2022 - Study
'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety.
Citation Text:
Mangin D, Risdon C, Lamarche L, et al. 'I think this medicine actually killed my wife': patient and family perspectives on s…
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psnet.ahrq.gov/issue/managing-prevention-retained-surgical-instruments-what-value-counting
September 25, 2008 - Study
Classic
Managing the prevention of retained surgical instruments: what is the value of counting?
Citation Text:
Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. …
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digital.ahrq.gov/ahrq-funded-projects/rural-health-information-technology-cooperative-promote-clinical-improvement
January 01, 2023 - A Rural Health Information Technology Cooperative to Promote Clinical Improvement
Project Final Report ( PDF , 203.76 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …
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psnet.ahrq.gov/issue/registered-nurses-and-medical-doctors-experiences-patient-safety-health-information-exchange
July 22, 2020 - Review
Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.
Citation Text:
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. Registered nurses' and medical doctors' experienc…
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psnet.ahrq.gov/issue/hand-hygiene-putting-nonsterile-gloves-intensive-care-unit-waste-health-care-worker-time
November 30, 2016 - Study
Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial.
Citation Text:
Rock C, Harris AD, Reich NG, et al. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a wa…
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psnet.ahrq.gov/issue/patient-harm-and-institutional-avoidability-out-hours-discharge-intensive-care-analysis-using
February 10, 2021 - Study
Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.
Citation Text:
Vollam S, Gustafson O, Morgan L, et al. Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis …
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psnet.ahrq.gov/issue/clinical-decision-support-alert-malfunctions-analysis-and-empirically-derived-taxonomy
December 04, 2016 - Study
Clinical decision support alert malfunctions: analysis and empirically derived taxonomy.
Citation Text:
Wright A, Ai A, Ash JS, et al. Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. J Am Med Inform Assoc. 2018;25(5):496-506. doi:10.1093/jam…
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psnet.ahrq.gov/issue/diagnostic-error-among-vulnerable-populations-presenting-emergency-department-cardiovascular
March 16, 2022 - Review
Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review.
Citation Text:
Herasevich S, Soleimani J, Huang C, et al. Diagnostic error among vulnerable populations prese…
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psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record-system-wide-patient
June 15, 2022 - Study
Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.
Citation Text:
Li L, Foer D, Hallisey RK, et al. Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative. J Patie…
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psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-patient-safety-and-magnet-designation-united
October 09, 2019 - Study
Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States.
Citation Text:
Hamadi H, Borkar SR, DHA LRM, et al. Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. J Patient Sa…
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psnet.ahrq.gov/issue/talking-about-falls-qualitative-exploration-spoken-communication-patients-fall-risks
July 20, 2022 - Study
Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention.
Citation Text:
McVey L, Alvarado N, Healey F, et al. Talking about falls: a qualitative exploration of spok…