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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
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psnet.ahrq.gov/issue/call-shift-fatigue-and-use-countermeasures-and-avoidance-strategies-certified-registered
March 15, 2023 - Study
Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey.
Citation Text:
Domen R, Connelly CD, Spence D. Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse …
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psnet.ahrq.gov/issue/meta-analysis-medication-administration-errors-african-hospitals
July 10, 2008 - Review
Meta-analysis of medication administration errors in African hospitals.
Citation Text:
Alemu W, Cimiotti JP. Meta-analysis of medication administration errors in African hospitals. J Healthc Qual. 2023;45(4):233-241. doi:10.1097/jhq.0000000000000396.
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psnet.ahrq.gov/issue/passing-yo-mama-test
February 15, 2023 - Commentary
Passing the "Yo' Mama" test.
Citation Text:
Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18.
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psnet.ahrq.gov/issue/residents-reflections-quality-improvement-temporal-stability-and-associations-preventability
September 20, 2011 - Study
Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.
Citation Text:
Wittich CM, Reed DA, Drefahl MM, et al. Residents' reflections on quality improvement: temporal stability and associations with preventab…
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psnet.ahrq.gov/issue/understanding-effect-resident-duty-hour-reform-qualitative-study
March 23, 2011 - Study
Understanding the effect of resident duty hour reform: a qualitative study.
Citation Text:
Pattani R, Wu PE, Dhalla IA. Resident duty hours in Canada: past, present and future. Can Med Assoc J. 2014;186(10). doi:10.1503/cmaj.131053.
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psnet.ahrq.gov/issue/falls-english-and-welsh-hospitals-national-observational-study-based-retrospective-analysis
June 15, 2011 - Study
Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports.
Citation Text:
Healey F, Scobie S, Oliver D, et al. Falls in English and Welsh hospitals: a national observational study based o…
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www.ahrq.gov/practiceimprovement/delivery-initiative/index.html
December 01, 2020 - Delivery System Research Initiative
ARRA Grants Initiative
Findings from a set of 10 grants on improving delivery systems and on spreading evidence-based practices through delivery systems; recommendations and methods for advancing delivery system research.
Improving the way that care is delivered is critic…
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psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events
October 19, 2022 - Study
Use of specific indicators to detect warfarin-related adverse events.
Citation Text:
Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404.
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psnet.ahrq.gov/issue/medication-errors-important-component-nonadherence-medication-outpatient-population-lung
June 23, 2021 - Study
Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients.
Citation Text:
Irani S, Seba P, Speich R, et al. Medication errors: an important component of nonadherence to medication in an outpatient population …
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psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician-order-entry-systems
May 27, 2011 - Review
Evaluation and certification of computerized physician order entry systems.
Citation Text:
Classen D, Avery A, Bates DW. Evaluation and certification of computerized provider order entry systems. J Am Med Inform Assoc. 2007;14(1):48-55.
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psnet.ahrq.gov/issue/safer-delivery-surgical-services-programme-controlled-and-after-intervention-studies-pre
October 12, 2016 - Book/Report
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis.
Citation Text:
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Poo…
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psnet.ahrq.gov/issue/aviation-pediatric-surgery
January 12, 2022 - Commentary
From aviation to pediatric surgery.
Citation Text:
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila). 2024;63(4):557-559. doi:10.1177/00099228231176631.
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psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons
April 03, 2013 - Study
Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons.
Citation Text:
Lee S, Park J. Giving up learning from failures? An examination of learning from one's own failures in the context of heart surgeons. Strat Manage J…
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psnet.ahrq.gov/issue/development-and-evaluation-1-day-interclerkship-program-medical-students-medical-errors-and
March 12, 2025 - Commentary
Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety.
Citation Text:
Moskowitz E, Veloski J, Fields SK, et al. Development and evaluation of a 1-day interclerkship program for medical students on medical error…
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psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk
November 08, 2013 - Study
Classic
Patient complaints and malpractice risk.
Citation Text:
Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951-7.
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psnet.ahrq.gov/issue/what-would-you-ideally-do-if-there-were-no-targets-ethnographic-study-unintended-consequences
July 27, 2011 - Study
What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings.
Citation Text:
Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…
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psnet.ahrq.gov/issue/emotional-exhaustion-and-workload-predict-clinician-rated-and-objective-patient-safety
February 14, 2017 - Study
Emotional exhaustion and workload predict clinician-rated and objective patient safety.
Citation Text:
Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Front Psychol. 2014;5:1573. doi:10.3389/fpsyg.2014.01573.
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psnet.ahrq.gov/issue/incidence-potentially-avoidable-urgent-readmissions-and-their-relation-all-cause-urgent
April 22, 2011 - Study
Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.
Citation Text:
van Walraven C, Jennings A, Taljaard M, et al. Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. Ca…
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psnet.ahrq.gov/issue/hospital-patients-reports-medical-errors-and-undesirable-events-their-health-care
July 06, 2012 - Study
Hospital patients' reports of medical errors and undesirable events in their health care.
Citation Text:
Davis R, Sevdalis N, Neale G, et al. Hospital patients' reports of medical errors and undesirable events in their health care. J Eval Clin Pract. 2013;19(5):875-81. doi:10.11…