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psnet.ahrq.gov/node/43898/psn-pdf
February 11, 2015 - Special Section on Patient Safety and Quality in
Healthcare.
February 11, 2015
Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155.
https://psnet.ahrq.gov/issue/special-section-patient-safety-and-quality-healthcare
Articles in this special issue explore patient safety from a sociotechnic…
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psnet.ahrq.gov/node/40577/psn-pdf
July 06, 2011 - Reducing potentially fatal errors associated with high
doses of insulin: a successful multifaceted
multidisciplinary prevention strategy.
July 6, 2011
Dooley MJ, Wiseman M, McRae A, et al. Reducing potentially fatal errors associated with high doses of
insulin: a successful multifaceted multidisciplinary preventio…
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psnet.ahrq.gov/node/36225/psn-pdf
July 10, 2008 - Transfers of patient care between house staff on internal
medicine wards: a national survey.
July 10, 2008
Horwitz LI, Krumholz HM, Green M, et al. Transfers of patient care between house staff on internal
medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-7.
https://psnet.ahrq.gov/issue/transfe…
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psnet.ahrq.gov/node/42360/psn-pdf
April 16, 2018 - Wrong-patient medication errors: an analysis of event
reports in Pennsylvania and strategies for prevention.
April 16, 2018
Yang A, Grissinger M. PA-PSRS Patient Saf Advis. June 2013;10:41-49.
https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-
strategies-preventio…
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psnet.ahrq.gov/node/43825/psn-pdf
January 28, 2015 - A systematic review of adult admissions to ICUs related
to adverse drug events.
January 28, 2015
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.
https://psnet.ahrq.gov/issue/systema…
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psnet.ahrq.gov/node/33617/psn-pdf
August 01, 2005 - In providing them with a process and
with a methodology by which to determine what their numbers need … to be, using the same methodology
from institution to institution, it empowers the nurses to determine
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psnet.ahrq.gov/node/33636/psn-pdf
July 01, 2006 - Safety officers need basic training in some form of process improvement methodology, such
as Six Sigma … Adverse drug event trigger tool: a practical methodology for
measuring medication related harm.
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psnet.ahrq.gov/node/50860/psn-pdf
February 05, 2020 - Does team reflexivity impact teamwork and
communication in interprofessional hospital-based
healthcare teams? A systematic review and narrative
synthesis.
February 5, 2020
McHugh SK, Lawton R, O'Hara JK, et al. Does team reflexivity impact teamwork and communication in
interprofessional hospital-based healthcare …
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psnet.ahrq.gov/node/73634/psn-pdf
August 25, 2021 - Validation of an electronic trigger to measure missed
diagnosis of stroke in emergency departments.
August 25, 2021
Vaghani V, Wei L, Mushtaq U, et al. Validation of an electronic trigger to measure missed diagnosis of
stroke in emergency departments. J Am Med Inform Assoc. 2021;28(10):2202-2211.
doi:10.1093/jamia…
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psnet.ahrq.gov/node/840142/psn-pdf
November 16, 2022 - The neglected barrier to medication use: a systematic
review of difficulties associated with opening medication
packaging.
November 16, 2022
Angel M, Bechard L, Pua YH, et al. The neglected barrier to medication use: a systematic review of
difficulties associated with opening medication packaging. Age Ageing. 2022…
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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - He developed the methodology for the hospital
standardized mortality ratios and was involved with the … In terms of the actual technology, we have a philosophy that if anyone can suggest a change in the
methodology
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psnet.ahrq.gov/node/34927/psn-pdf
June 23, 2009 - Health Care Quality and Disparities: Lessons from the
First National Reports.
June 23, 2009
Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88.
https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
Highlights from AHRQ's two inaugural reports, the 2003 National …
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psnet.ahrq.gov/node/41390/psn-pdf
January 31, 2013 - A systematic review of patient tracking systems for use
in the pediatric emergency department.
January 31, 2013
Dobson I, Doan Q, Hung G. A systematic review of patient tracking systems for use in the pediatric
emergency department. J Emerg Med. 2013;44(1):242-8. doi:10.1016/j.jemermed.2012.02.017.
https://psnet.a…
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psnet.ahrq.gov/node/46614/psn-pdf
November 29, 2017 - Interventions to improve hand hygiene compliance in the
ICU: a systematic review.
November 29, 2017
Lydon S, Power M, McSharry J, et al. Interventions to Improve Hand Hygiene Compliance in the ICU. Crit
Care Med. 2017;45(11). doi:10.1097/ccm.0000000000002691.
https://psnet.ahrq.gov/issue/interventions-improve-hand…
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psnet.ahrq.gov/node/36335/psn-pdf
February 01, 2011 - Rapid response teams—walk, don't run.
February 1, 2011
Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13).
doi:10.1001/jama.296.13.1645.
https://psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run
Rapid response teams (RRTs) have been widely advocated as a means of aver…
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psnet.ahrq.gov/node/35006/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Second Annual Patient
Safety in American Hospitals Study.
October 25, 2013
Health Grades, Inc; 2005.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-second-annual-patient-safety-american-hospitals-
study
The first version of this now annual report on the safety of hospitalized …
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psnet.ahrq.gov/node/35619/psn-pdf
June 24, 2010 - Studying patient safety in health care organizations:
accentuate the qualitative.
June 24, 2010
Hoff TJ, Sutcliffe K. Studying patient safety in health care organizations: accentuate the qualitative. Jt
Comm J Qual Patient Saf. 2006;32(1):5-15.
https://psnet.ahrq.gov/issue/studying-patient-safety-health-care-organ…
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - The most frequently cited adult studies using a retrospective methodology ( 22-23 ) revealed adverse … This methodology was valuable in the early days of the patient safety field by highlighting the major … Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients … Methodology and rationale for the measurement of harm with trigger tools. … Adverse drug event trigger tool: a practical methodology for measuring medication related harm.
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psnet.ahrq.gov/node/40820/psn-pdf
October 05, 2011 - Influence of house-staff experience on teaching-hospital
mortality: the "July Phenomenon" revisited.
October 5, 2011
van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital
mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7):389-94. doi:10.1002/jhm.917.
htt…
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psnet.ahrq.gov/node/44674/psn-pdf
December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care
at Baylor Scott & White Health.
December 18, 2017
Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
Since the publication of the Inst…