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psnet.ahrq.gov/issue/patient-engagement-surgical-site-infection-prevention-expert-panel-perspective
June 03, 2020 - Review
Patient engagement with surgical site infection prevention: an expert panel perspective.
Citation Text:
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45.…
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psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis
March 23, 2012 - Study
Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.
Citation Text:
Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge su…
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psnet.ahrq.gov/issue/digital-health-intervention-patient-safety-children-and-parents-scoping-review
January 23, 2017 - Review
Digital health intervention on patient safety for children and parents: a scoping review.
Citation Text:
Park J, Jeon H, Choi EK. Digital health intervention on patient safety for children and parents: a scoping review. J Adv Nurs. 2024;80(5):1750-1760. doi:10.1111/jan.15954.
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psnet.ahrq.gov/issue/cultural-transformation-after-implementation-crew-resource-management-it-really-possible
November 16, 2022 - Study
Cultural transformation after implementation of crew resource management: is it really possible?
Citation Text:
Hefner JL, Hilligoss B, Knupp A, et al. Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible? Am J Med Qual. 2017;32(4):384-390…
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psnet.ahrq.gov/issue/stakeholders-safety-patient-reports-unsafe-clinical-behaviors-distinguish-hospital-mortality
November 29, 2023 - Study
Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates.
Citation Text:
Reader TW, Gillespie A. Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates. J Appl Psychol. 2021;106(3):4…
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psnet.ahrq.gov/issue/serious-incidents-after-death-content-analysis-incidents-reported-national-database
October 03, 2018 - Study
Serious incidents after death: content analysis of incidents reported to a national database.
Citation Text:
Yardley IE, Carson-Stevens A, Donaldson LJ. Serious incidents after death: content analysis of incidents reported to a national database. J R Soc Med. 2017;111(2):57-64. doi…
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psnet.ahrq.gov/issue/impact-computerized-clinical-decision-support-system-reducing-inappropriate-antimicrobial-use
December 09, 2015 - Study
Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial.
Citation Text:
McGregor JC, Weekes E, Forrest GN, et al. Impact of a computerized clinical decision support system on reducing inappropriate antim…
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psnet.ahrq.gov/issue/simulation-study-rested-versus-sleep-deprived-anesthesiologists
September 13, 2017 - Study
Classic
Simulation study of rested versus sleep-deprived anesthesiologists.
Citation Text:
Howard SK, Gaba DM, Smith B, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345-1355. doi:10.1097/00000542-…
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psnet.ahrq.gov/issue/improving-our-understanding-multi-tasking-healthcare-drawing-together-cognitive-psychology
July 19, 2018 - Review
Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature.
Citation Text:
Douglas HE, Raban MZ, Walter SR, et al. Improving our understanding of multi-tasking in healthcare: Drawing together the cognitive psycho…
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psnet.ahrq.gov/issue/henry-ford-production-system-reduction-surgical-pathology-process-misidentification-defects
July 16, 2013 - Study
The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.
Citation Text:
Zarbo RJ, Tuthill M, D'Angelo R, et al. The Henry Ford Production System: reduction of surgical pathology in-p…
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psnet.ahrq.gov/issue/ensuring-access-medications-us-during-covid-19-pandemic
May 08, 2017 - Commentary
Ensuring access to medications in the US during the COVID-19 pandemic.
Citation Text:
Alexander GC, Qato DM. Ensuring access to medications in the US during the COVID-19 pandemic. JAMA. 2020;324(1):31-32. doi:10.1001/jama.2020.6016.
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psnet.ahrq.gov/issue/clinical-oversight-conceptualizing-relationship-between-supervision-and-safety
June 23, 2010 - Study
Clinical oversight: conceptualizing the relationship between supervision and safety.
Citation Text:
Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080-5.
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psnet.ahrq.gov/issue/role-patients-and-their-relatives-speaking-about-their-own-safety-qualitative-study-acute
January 19, 2012 - Study
The role of patients and their relatives in 'speaking up' about their own safety—a qualitative study of acute illness.
Citation Text:
Rainey H, Ehrich K, Mackintosh N, et al. The role of patients and their relatives in 'speaking up' about their own safety - a qualitative study of a…
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psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
November 16, 2022 - Study
Personal health records: a randomized trial of effects on elder medication safety.
Citation Text:
Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…
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psnet.ahrq.gov/issue/strategies-improving-value-radiology-report-retrospective-analysis-errors-formally-over-read
November 10, 2021 - Study
Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies.
Citation Text:
Kabadi SJ, Krishnaraj A. Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read…
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psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care
November 28, 2016 - Study
What do patients and relatives know about problems and failures in care?
Citation Text:
Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100.
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psnet.ahrq.gov/issue/high-nursing-staff-turnover-nursing-homes-offers-important-quality-information
September 16, 2020 - Study
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High nursing staff turnover in nursing homes offers important quality information.
Citation Text:
Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information. Health Aff (Millwood). 2021;40(3):384…
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www.ahrq.gov/news/newsroom/case-studies/cquips0603.html
October 01, 2014 - AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation
Search All Impact Case Studies
November 2005
The Palo Alto Medical Foundation, a multi-specialty medical group located near San Francisco, is now using AHRQ's Hospital Survey on Patient Safety Culture . The first…
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psnet.ahrq.gov/issue/what-does-safety-commitment-mean-leaders-multi-method-investigation
September 11, 2024 - Study
What does safety commitment mean to leaders? A multi-method investigation.
Citation Text:
Fruhen LS, Griffin MA, Andrei DM. What does safety commitment mean to leaders? A multi-method investigation. J Safety Res. 2019;68:203-214. doi:10.1016/j.jsr.2018.12.011.
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psnet.ahrq.gov/issue/effect-electronic-health-records-ambulatory-care-retrospective-serial-cross-sectional-study
March 24, 2019 - Study
Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study.
Citation Text:
Garrido T, Jamieson L, Zhou Y, et al. Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study. BMJ. 2005;330(7491):581…