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psnet.ahrq.gov/issue/evaluation-detected-medication-errors-within-operating-room-academic-medical-center
October 19, 2022 - Study
Evaluation of detected medication errors within the operating room at an academic medical center.
Citation Text:
Wolf M, Rolf J, Nelson D, et al. Evaluation of detected medication errors within the operating room at an academic medical center. Hosp Pharm. 2023;58(3):309-314. doi:10…
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psnet.ahrq.gov/issue/developing-systematic-approach-safer-medication-use-during-pregnancy-summary-centers-disease
February 17, 2011 - Commentary
Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting.
Citation Text:
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication use during p…
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psnet.ahrq.gov/issue/white-paper-recommendation-systems-based-practice-competency
December 18, 2017 - Commentary
White paper on recommendation for systems-based practice competency.
Citation Text:
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force: White Paper on Recommendation for Systems-Based Practice Competency. J Nurs Care Qual. 2017;32(4):354-358. doi:10.1097/NC…
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psnet.ahrq.gov/issue/systematic-review-adult-admissions-icus-related-adverse-drug-events
March 16, 2016 - Review
A systematic review of adult admissions to ICUs related to adverse drug events.
Citation Text:
Jolivot P-A, Hindlet P, Pichereau C, et al. A systematic review of adult admissions to ICUs related to adverse drug events. Crit Care. 2014;18(6):643. doi:10.1186/s13054-014-0643-5.
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psnet.ahrq.gov/issue/intraoperative-handoffs-among-anesthesia-providers-increase-incidence-documentation-errors
April 12, 2019 - Study
Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.
Citation Text:
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the Incidence of Documentation Errors for Contr…
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psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-japan
September 25, 2019 - Study
Impact of miscommunication in medical dispute cases in Japan.
Citation Text:
Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028.
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psnet.ahrq.gov/issue/leadership-strategies-medical-school-deans-promote-quality-and-safety
August 10, 2022 - Commentary
Leadership strategies of medical school deans to promote quality and safety.
Citation Text:
Griner PF. Leadership strategies of medical school deans to promote quality and safety. Jt Comm J Qual Patient Saf. 2007;33(2):63-72.
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psnet.ahrq.gov/issue/implementation-colour-coded-universal-protocol-safety-initiative-guatemala
October 31, 2017 - Study
Implementation of a colour-coded universal protocol safety initiative in Guatemala.
Citation Text:
Taicher BM, Tew S, Figueroa L, et al. Implementation of a colour-coded universal protocol safety initiative in Guatemala. BMJ Qual Saf. 2018;27(8). doi:10.1136/bmjqs-2017-007217.
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psnet.ahrq.gov/issue/disclosing-errors-and-adverse-events-intensive-care-unit
February 17, 2017 - Study
Disclosing errors and adverse events in the intensive care unit.
Citation Text:
Boyle DJ, O'Connell D, Platt FW, et al. Disclosing errors and adverse events in the intensive care unit. Crit Care Med. 2006;34(5):1532-7.
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psnet.ahrq.gov/issue/non-clinical-errors-using-voice-recognition-dictation-software-radiology-reports
December 29, 2014 - Study
Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit.
Citation Text:
Chang CA, Strahan R, Jolley D. Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit. J Digit Imaging. …
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psnet.ahrq.gov/issue/use-who-surgical-safety-checklist-trauma-and-orthopaedic-patients
August 30, 2017 - Study
Use of the WHO surgical safety checklist in trauma and orthopaedic patients.
Citation Text:
Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop. 2011;35(6):897-901. doi:10.1007/s00264-010-1112-7.
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psnet.ahrq.gov/issue/are-quality-improvement-collaboratives-effective-systematic-review
August 02, 2015 - Review
Are quality improvement collaboratives effective? A systematic review.
Citation Text:
Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf. 2018;27(3):226-240. doi:10.1136/bmjqs-2017-006926.
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psnet.ahrq.gov/issue/implementation-resident-work-hour-restrictions-associated-reduction-mortality-and-provider
December 21, 2014 - Study
Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients.
Citation Text:
Privette AR, Shackford SR, Osler T, et al. Implementation of resident …
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psnet.ahrq.gov/issue/key-considerations-ensuring-safe-regional-telehealth-care-model-systematic-review
August 25, 2021 - Review
Key considerations in ensuring a safe regional telehealth care model: a systematic review.
Citation Text:
Haveland S, Islam S. Key considerations in ensuring a safe regional telehealth care model: a systematic review. Telemed J E Health. 2022;28(5):602-612. doi:10.1089/tmj.2020.05…
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psnet.ahrq.gov/issue/why-simulation-matters-systematic-review-medical-errors-occurring-during-simulated-health
September 25, 2019 - Citation
Related Resources From the Same Author(s)
Debunking the myth that the majority
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - phenomenon occurs because of the sheer number of alerts, and it is compounded by the fact that the vast majority … Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.