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  1. psnet.ahrq.gov/issue/how-common-are-cognitive-errors-cases-presented-emergency-medicine-resident-morbidity-and
    May 08, 2019 - Study How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences? Citation Text: Chu D, Xiao J, Shah P, et al. How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?…
  2. psnet.ahrq.gov/issue/preventive-surgical-site-infection-bundle-colorectal-surgery-effective-approach-surgical-site
    November 16, 2022 - Study The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. Citation Text: Keenan JE, Speicher PJ, Thacker JKM, et al. The preventive surgical site infection bundle in colorectal surge…
  3. psnet.ahrq.gov/issue/effects-enhanced-discharge-planning-intervention-hospitalized-older-adults-randomized-trial
    September 21, 2016 - Study Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Citation Text: Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Gerontologist.…
  4. psnet.ahrq.gov/issue/review-incidents-related-health-information-technology-swedish-healthcare-characterise-system
    December 20, 2023 - Study A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. Citation Text: Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in Sw…
  5. psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
    June 14, 2023 - Study Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. Citation Text: Fredheim OMS, Klingenberg E, Lindahl AK. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. J Palliat Med.…
  6. psnet.ahrq.gov/issue/how-well-do-incident-reporting-systems-work-inpatient-psychiatric-units
    September 05, 2018 - Study How well do incident reporting systems work on inpatient psychiatric units? Citation Text: Reilly CA, Cullen SW, Watts B, et al. How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units? Jt Comm J Qual Patient Saf. 2019;45(1):63-69. doi:10.1016/j.jcjq.2018.05.002.…
  7. psnet.ahrq.gov/issue/dynamic-risk-management-approach-reducing-harm-invasive-bedside-procedures-performed-during
    April 13, 2022 - Commentary A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. Citation Text: Warm E, Ahmad Y, Kinnear B, et al. A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.…
  8. psnet.ahrq.gov/issue/squire-guidelines-evaluation-field-5-years-post-release
    November 18, 2016 - Study The SQUIRE Guidelines: an evaluation from the field, 5 years post release. Citation Text: Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116. Copy Cita…
  9. psnet.ahrq.gov/issue/unanticipated-death-after-discharge-home-emergency-department
    November 16, 2022 - Study Unanticipated death after discharge home from the emergency department. Citation Text: Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018. Copy Citati…
  10. psnet.ahrq.gov/issue/getting-board-board-engaging-hospital-boards-quality-and-patient-safety
    November 23, 2016 - Study Getting the board on board: engaging hospital boards in quality and patient safety. Citation Text: Joshi MS, Hines S. Getting the board on board: Engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006;32(4):179-87. Copy Citation Format: …
  11. psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
    July 16, 2013 - Commentary Getting it right for patient safety: specimen collection process improvement from operating room to pathology. Citation Text: D'Angelo R, Mejabi O. Getting It Right for Patient Safety:  Specimen Collection Process Improvement From Operating Room to Pathology. Am J Clin Pathol.…
  12. psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
    July 28, 2021 - Commentary The Child Health PSO at 10 years: an emerging learning network. Citation Text: Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network. Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449. Copy Citation Format: …
  13. psnet.ahrq.gov/issue/survey-national-drug-shortage-effect-anesthesia-and-patient-safety-patient-perspective
    May 23, 2018 - Study Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective. Citation Text: Hsia IK-H, Dexter F, Logvinov I, et al. Survey of the National Drug Shortage Effect on Anesthesia and Patient Safety: A Patient Perspective. Anesth Analg. 2015;121(2)…
  14. psnet.ahrq.gov/issue/what-defines-high-performing-health-system-systematic-review
    August 17, 2022 - Review What defines a high-performing health system: a systematic review. Citation Text: Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.…
  15. psnet.ahrq.gov/issue/identification-errors-involving-clinical-laboratories-college-american-pathologists-q-probes
    February 15, 2010 - Study Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Citation Text: Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical …
  16. psnet.ahrq.gov/issue/defining-minimum-necessary-anticoagulation-related-communication-discharge-consensus-care
    March 04, 2020 - Study Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Citation Text: Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Commu…
  17. psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative
    January 22, 2016 - Study Who applies an intervention to influence cultural attributes in a quality improvement collaborative? Citation Text: Hsu Y-J, Marsteller JA. Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative? J Patient Saf. 2020;16(1):1-6. Copy Cit…
  18. psnet.ahrq.gov/issue/accuracy-send-out-test-ordering-college-american-pathologists-q-probes-study-ordering
    November 12, 2008 - Study Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. Citation Text: Valenstein PN, Walsh MK, Stankovic AK. Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of o…
  19. psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
    July 14, 2009 - Study Competition and health plan performance: evidence from health maintenance organization insurance markets. Citation Text: Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from health maintenance organization insurance markets. Med Care.…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - doctor at the time of discharge, or immediately faxed a discharge summary or letter to convey the last measured … Effect of a simple two-step warfarin dosing algorithm on anticoagulant control as measured by time in

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