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psnet.ahrq.gov/issue/association-nurse-workload-missed-nursing-care-neonatal-intensive-care-unit
September 27, 2017 - Study
Emerging Classic
Association of nurse workload with missed nursing care in the neonatal intensive care unit.
Citation Text:
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Uni…
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psnet.ahrq.gov/issue/nurses-experience-decision-making-processes-missed-nursing-care-qualitative-study
May 11, 2022 - Study
The nurse's experience of decision-making processes in missed nursing care: a qualitative study.
Citation Text:
Abdelhadi N, Drach‐Zahavy A, Srulovici E. The nurse’s experience of decision‐making processes in missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-217…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/clinical-case-scenarios.html
July 01, 2023 - Clinical Case Scenarios
AHRQ Safety Program for Perinatal Care, Phase 2
The two clinical case scenarios below illustrate 10 teamwork tools and strategies for improving perinatal care. One scenario focuses on obstetric hemorrhage, and the other scenario focuses on severe hypertension in pregnancy. Both scena…
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psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual
July 27, 2022 - Study
Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.
Citation Text:
Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national health ca…
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psnet.ahrq.gov/issue/guidance-health-care-leaders-during-recovery-stage-covid-19-pandemic-consensus-statement
December 21, 2017 - Commentary
Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement.
Citation Text:
Geerts JM, Kinnair D, Taheri P, et al. Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. JAMA Ne…
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psnet.ahrq.gov/issue/exploring-situational-awareness-diagnostic-errors-primary-care
September 20, 2011 - Study
Exploring situational awareness in diagnostic errors in primary care.
Citation Text:
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
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psnet.ahrq.gov/issue/design-and-implementation-analgesia-sedation-and-paralysis-order-set-enhance-compliance-pro
February 09, 2022 - Study
Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU.
Citation Text:
Procaccini D, Rapaport R, Petty BG, et al. Design and Impleme…
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psnet.ahrq.gov/issue/lifetime-prevalence-and-correlates-patient-perceived-medical-errors-experienced-us-ambulatory
June 09, 2021 - Study
Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study.
Citation Text:
Sundwall DN, Munger MA, Tak CR, et al. Lifetime prevalence and correlates of patient-perceived medical errors experienced in t…
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psnet.ahrq.gov/issue/overrides-medication-alerts-ambulatory-care
September 01, 2016 - Study
Overrides of medication alerts in ambulatory care.
Citation Text:
Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311. doi:10.1001/archinternmed.2008.551.
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psnet.ahrq.gov/issue/impact-who-surgical-safety-checklist-relative-its-design-and-intended-use-systematic-review
March 17, 2021 - Review
Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.
Citation Text:
Sotto KT, Burian BK, Brindle ME. Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review…
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psnet.ahrq.gov/issue/association-between-mobile-telephone-interruptions-and-medication-administration-errors
June 29, 2009 - Study
Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.
Citation Text:
Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatr…
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psnet.ahrq.gov/issue/medication-discrepancies-resident-sign-outs-and-their-potential-harm
March 28, 2011 - Study
Medication discrepancies in resident sign-outs and their potential to harm.
Citation Text:
Arora V, Kao J, Lovinger D, et al. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. 2007;22(12):1751-5.
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psnet.ahrq.gov/issue/effects-i-pass-nursing-handoff-bundle-communication-quality-and-workflow
November 12, 2014 - Study
Effects of the I-PASS nursing handoff bundle on communication quality and workflow.
Citation Text:
Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-0…
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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/impact-structured-interdisciplinary-bedside-rounding-patient-outcomes-large-academic-health
December 09, 2020 - Study
Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.
Citation Text:
Sunkara PR, Islam T, Bose A, et al. Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre. BMJ Qual …
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psnet.ahrq.gov/issue/improving-safety-hospitalized-patients-much-progress-many-challenges-remain
September 24, 2017 - Commentary
Improving safety for hospitalized patients: much progress but many challenges remain.
Citation Text:
Kronick R, Arnold S, Brady J. Improving Safety for Hospitalized Patients: Much Progress but Many Challenges Remain. JAMA. 2016;316(5):489-90. doi:10.1001/jama.2016.7887.
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psnet.ahrq.gov/issue/miscarriage-treatment-related-morbidities-and-adverse-events-hospitals-ambulatory-surgery
August 10, 2022 - Study
Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.
Citation Text:
Roberts SCM, Beam N, Liu G, et al. Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers,…
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psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey
April 29, 2018 - Study
Analysis of clinical decision support system malfunctions: a case series and survey.
Citation Text:
Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…
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www.ahrq.gov/patient-safety/resources/learning-lab/transdisciplinary-learning-long-desc.html
June 01, 2020 - Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste
Long Description
Principal Investigator: Adam Sapirstein, M.D., Johns Hopkins University, Baltimore, MD
AHRQ Grant No.: HS23553
Project Period: 09/30/14–03/29/19
Description: The goal of the Johns Hopkins Armstrong Institute L…
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www.ahrq.gov/patient-safety/resources/learning-lab/owll-long-desc.html
August 01, 2025 - Open Wide Learning Lab (OWLL): Improving Patient Safety in Dentistry
Principal Investigator: Muhammad Walji, Ph.D., University of Texas Health Science Center at Houston, Houston, TX AHRQ Grant No.: HS027268 Project Period: 09/09/19-08/31/24 Description: OWLL aimed to improve patient safety in dental sett…