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  1. psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators
    June 02, 2010 - Study Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Citation Text: Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.…
  2. psnet.ahrq.gov/issue/optimizing-therapy-prevent-avoidable-hospital-admissions-multimorbid-older-adults-operam
    December 21, 2022 - Study Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. Citation Text: Blum MR, Sallevelt B, Spinewine A, et al. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (O…
  3. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/149-cusp-tip-sheet-assembling-team.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention CUSP Tip Sheet: Assembling the CUSP Team ICU & Non-ICU Purpose Teamwork and interprofessional collaboration are important to high-quality patient care. A culture of teamwork and learning from mistakes helps improve patient safety. The Comprehensive Unit-based Safety Program (CUS…
  4. www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
    April 01, 2018 - Guide for Developing a Community-Based Patient Safety Advisory Council Chapter 2. Patient Safety Advisory Councils The success of any team requires active participation from every member. The approach health care systems traditionally take neglects the most critical member of the team—the patient. Programs an…
  5. www.ahrq.gov/research/findings/final-reports/ptflow/references.html
    October 01, 2018 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals References Previous Page Next Page Table of Contents Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals Acknowledgments Executive Summary Section 1. The Need to Addres…
  6. psnet.ahrq.gov/issue/effect-burnout-among-physicians-observed-adverse-patient-outcomes-literature-review
    October 27, 2021 - Review Effect of burnout among physicians on observed adverse patient outcomes: a literature review. Citation Text: Mangory KY, Ali LY, Rø KI, et al. Effect of burnout among physicians on observed adverse patient outcomes: a literature review. BMC Health Serv Res. 2021;21(1):369. doi:10.…
  7. psnet.ahrq.gov/issue/hospitalizations-and-deaths-related-adverse-drug-events-worldwide-systematic-review-studies
    May 04, 2022 - Review Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies with national coverage. Citation Text: Silva LT, Modesto ACF, Amaral RG, et al. Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies wit…
  8. psnet.ahrq.gov/issue/compensation-claims-danish-emergency-care-identifying-hot-spots-and-blind-spots-quality-care
    November 03, 2021 - Study Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care. Citation Text: Morsø L, Birkeland S, Walløe S, et al. Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care. Jt Comm J Qu…
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/044-vap-prevention-essential.docx
    October 01, 2024 - Ventilator-Associated Pneumonia (VAP) Prevention Essential Practices1 Avoid intubation if possible.2-3 Consider alternative strategies, such as, high flow O2 or noninvasive positive pressure ventilation. Consider each patient’s clinical scenario to determine the most appropriate strategy. Minimize sedation.2-5 Determ…
  10. psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
    June 16, 2021 - Study Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? Citation Text: Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualita…
  11. psnet.ahrq.gov/issue/what-counts-voiceable-concern-decisions-about-speaking-out-hospitals-qualitative-study
    June 16, 2021 - Study What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study. Citation Text: Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study. J Health Serv Res…
  12. psnet.ahrq.gov/issue/development-rapid-response-capabilities-large-covid-19-alternate-care-site-using-failure
    September 16, 2020 - Commentary Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. Citation Text: Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate ca…
  13. psnet.ahrq.gov/issue/interorganizational-health-information-exchange-related-patient-safety-incidents-descriptive
    November 10, 2021 - Study Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. Citation Text: Hyvämäki P, Sneck S, Meriläinen M, et al. Interorganizational health information exchange-related patient safety incidents: a descriptive…
  14. psnet.ahrq.gov/issue/associations-between-stopping-prescriptions-opioids-length-opioid-treatment-and-overdose-or
    April 05, 2017 - Study Classic Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. Citation Text: Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescrip…
  15. psnet.ahrq.gov/issue/healthcare-professionals-experience-psychological-safety-voice-and-silence
    March 18, 2020 - Study Healthcare professionals experience of psychological safety, voice, and silence. Citation Text: O'Donovan R, De Brún A, McAuliffe E. Healthcare professionals experience of psychological safety, voice, and silence. Front Psychol. 2021;12:626689. doi:10.3389/fpsyg.2021.626689. Copy…
  16. psnet.ahrq.gov/issue/scoping-review-real-time-automated-clinical-deterioration-alerts-and-evidence-impacts
    February 16, 2022 - Review A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes. Citation Text: Blythe R, Parsons R, White NM, et al. A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hos…
  17. psnet.ahrq.gov/issue/intraoperative-deaths-who-why-and-can-we-prevent-them
    November 04, 2020 - Study Intraoperative deaths: who, why, and can we prevent them? Citation Text: Dorken Gallastegi A, Mikdad S, Kapoen C, et al. Intraoperative deaths: who, why, and can we prevent them? J Surg Res. 2022;274:185-195. doi:10.1016/j.jss.2022.01.007. Copy Citation Format: DOI Go…
  18. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-cancer-care-yost.pdf
    June 13, 2017 - Introducing the CAHPS Cancer Care Survey ©2017 MFMER | slide-32 CAHPS Cancer Care Survey Sampling and Administration Recommendations Kathleen Yost, PhD Introducing the New AHRQ Survey for Cancer Centers June 13, 2017 ©2017 MFMER | slide-33 Acknowledgements Mayo Clinic Study Team Tim Beebe (University of MN…
  19. psnet.ahrq.gov/issue/malpractice-cases-breast-surgery-assessment-litigation-involving-surgeons
    August 04, 2021 - Study Malpractice cases in breast surgery: an assessment of litigation involving surgeons. Citation Text: Fan B, Pardo J, Yu-Moe CW, et al. Malpractice cases in breast surgery: an assessment of litigation involving surgeons. Ann Surg Oncol. 2021;28(13):8109-8115. doi:10.1245/s10434-021-1…
  20. psnet.ahrq.gov/issue/tall-man-lettering-and-potential-prescription-errors-time-series-analysis-42-childrens
    January 12, 2012 - Study Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. Citation Text: Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hosp…