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psnet.ahrq.gov/issue/effect-lean-quality-improvement-implementation-program-surgical-pathology-specimen
December 03, 2014 - Study
The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency.
Citation Text:
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation program on surgical …
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psnet.ahrq.gov/issue/introduction-medical-emergency-team-met-system-cluster-randomised-controlled-trial
January 18, 2011 - Study
Classic
Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.
Citation Text:
Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. L…
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psnet.ahrq.gov/issue/harmful-medication-errors-children-5-year-analysis-data-usps-medmarxr-program
July 12, 2010 - Study
Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX(R) program.
Citation Text:
Hicks RW, Becker SC, Cousins DD. Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program. J Pediatr Nurs. 2006;21(4):290-8.
…
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psnet.ahrq.gov/issue/first-do-no-harm-practitioners-ability-diagnose-system-weaknesses-and-improve-safety-critical
March 03, 2021 - Commentary
First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.
Citation Text:
English M, Ogola M, Aluvaala J, et al. First do no harm: practitioners’ ability to ‘diagnose’ system weaknesses and …
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psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
June 18, 2019 - Study
Interpersonal and organizational dynamics are key drivers of failure to rescue.
Citation Text:
Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.201…
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psnet.ahrq.gov/issue/wrong-administration-route-medications-domestic-setting-review-underestimated-public-health
December 15, 2021 - Review
Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic.
Citation Text:
Gualano MR, Lo Moro G, Voglino G, et al. Wrong administration route of medications in the domestic setting: a review of an underestimated public hea…
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psnet.ahrq.gov/issue/medication-reconciliation-during-transitions-care-patient-safety-strategy-systematic-review
January 12, 2022 - Review
Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.
Citation Text:
Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158…
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psnet.ahrq.gov/issue/association-household-opioid-availability-and-prescription-opioid-initiation-among-household
April 24, 2018 - Study
Association of household opioid availability and prescription opioid initiation among household members.
Citation Text:
Seamans MJ, Carey TS, Westreich DJ, et al. Association of Household Opioid Availability and Prescription Opioid Initiation Among Household Members. JAMA Intern Me…
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psnet.ahrq.gov/issue/systematic-review-impact-health-information-technology-quality-efficiency-and-costs-medical
March 30, 2022 - Review
Classic
Systematic review: impact of health information technology on quality, efficiency, and costs of medical care.
Citation Text:
Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and …
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psnet.ahrq.gov/issue/stard-2015-guidelines-reporting-diagnostic-accuracy-studies-explanation-and-elaboration
February 14, 2006 - Commentary
STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration.
Citation Text:
Cohen JF, Korevaar DA, Altman DG, et al. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open. 2016;6(11):e012799. doi…
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psnet.ahrq.gov/issue/optimizing-post-acute-care-patient-safety-scoping-review-multifactorial-fall-prevention
January 12, 2022 - Review
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
Citation Text:
Leland NE, Lekovitch C, Martínez J, et al. Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention int…
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psnet.ahrq.gov/issue/artificial-intelligence-powered-chatbots-search-engines-cross-sectional-study-quality-and
April 21, 2021 - Study
Artificial intelligence-powered chatbots in search engines: a cross-sectional study on the quality and risks of drug information for patients.
Citation Text:
Andrikyan W, Sametinger SM, Kosfeld F, et al. Artificial intelligence-powered chatbots in search engines: a cross-sectional …
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psnet.ahrq.gov/issue/orthopaedic-error-index-development-and-application-novel-national-indicator-assessing
July 18, 2016 - Study
The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.
Citation Text:
Panesar SS, Netuveli G, Carson-Stevens A, et al. The orthopaedic error index: development and…
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psnet.ahrq.gov/issue/reporting-improving-how-root-cause-analysis-teams-shape-patient-safety-culture
July 31, 2024 - Study
From reporting to improving: how root cause analysis in teams shape patient safety culture.
Citation Text:
Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-18…
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psnet.ahrq.gov/issue/development-and-performance-evaluation-medicines-optimisation-assessment-tool-moat-prognostic
March 18, 2020 - Study
Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.
Citation Text:
Geeson C, Wei L, Franklin BD. Development and performance evaluation of the M…
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psnet.ahrq.gov/issue/influence-shift-duration-cognitive-performance-emergency-physicians-prospective-cross
November 07, 2018 - Study
Influence of shift duration on cognitive performance of emergency physicians: a prospective cross-sectional study.
Citation Text:
Persico N, Maltese F, Ferrigno C, et al. Influence of Shift Duration on Cognitive Performance of Emergency Physicians: A Prospective Cross-Sectional Stu…
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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.