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psnet.ahrq.gov/issue/case-report-medication-error-look-alike-packaging-classic-surrogate-marker-unsafe-system
January 12, 2022 - Commentary
Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.
Citation Text:
Schnoor J, Rogalski C, Frontini R, et al. Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Patien…
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psnet.ahrq.gov/issue/what-every-health-lawyer-should-know-about-patient-safety-and-quality-improvement-act-2005
January 23, 2017 - Commentary
What every health lawyer should know about the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Hanzal M. What every health lawyer should know about the Patient Safety and Quality Improvement Act of 2005. J Health Life Sci Law. 2020;13(2):71-88.
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psnet.ahrq.gov/issue/resident-attitudes-regarding-impact-80-duty-hours-work-standards
August 24, 2015 - Study
Resident attitudes regarding the impact of the 80–duty-hours work standards.
Citation Text:
Zonia SC, 2nd RJLB, Stommel M, et al. Resident attitudes regarding the impact of the 80-duty-hours work standards. J Am Osteopath Assoc. 2005;105(7):307-313. https://www.degruyter.com/docu…
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psnet.ahrq.gov/issue/improving-transfusion-safety-implementation-comprehensive-computerized-bar-code-based
October 19, 2022 - Study
Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors.
Citation Text:
Askeland RW, McGrane S, Levitt JS, et al. Improving transfusion safety: implementation of a comprehensive computerized b…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/3_julie_susi.pdf
April 01, 2014 - Achieving Excellence Across All CG-CAHPS Core Measures: Lessons from Top-Performing Medical Practices
Mercy Hospital
Fore River Campus
Portland, Maine
23
Breast Care Specialists of Maine
A two-surgeon practice, we take pride in offering
timely, accurate consultation and treatment for
benign and malignant …
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psnet.ahrq.gov/issue/review-best-practices-intravenous-push-medication-administration
February 21, 2018 - Review
A review of best practices for intravenous push medication administration.
Citation Text:
Lenz JR, Degnan DD, Hertig JB, et al. A Review of Best Practices for Intravenous Push Medication Administration. J Infus Nurs. 2017;40(6):354-358. doi:10.1097/NAN.0000000000000247.
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psnet.ahrq.gov/issue/shortage-perioperative-drugs-implications-anesthesia-practice-and-patient-safety
April 11, 2018 - Commentary
Shortage of perioperative drugs: implications for anesthesia practice and patient safety.
Citation Text:
De Oliveira GS, Theilken LS, McCarthy R. Shortage of perioperative drugs: implications for anesthesia practice and patient safety. Anesth Analg. 2011;113(6):1429-35. doi:10…
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psnet.ahrq.gov/issue/engineered-solution-maladministration-spinal-injections
March 14, 2022 - Study
An engineered solution to the maladministration of spinal injections.
Citation Text:
Lawton R, Gardner P, Green B, et al. An engineered solution to the maladministration of spinal injections. Qual Saf Health Care. 2009;18(6):492-5. doi:10.1136/qshc.2007.025767.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-101-webcast-overview-surveys.pdf
January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Gray
Overview of the SOPS Surveys
Laura Gray, MPH
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
What is Patient Safety Culture?
Organization
13
What are the SOPS Surveys?
• Surveys of providers and st…
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psnet.ahrq.gov/issue/surgical-management-and-outcomes-165-colonoscopic-perforations-single-institution
November 16, 2022 - Study
Surgical management and outcomes of 165 colonoscopic perforations from a single institution.
Citation Text:
Iqbal CW, Cullinane DC, Schiller HJ, et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg. 2008;143(7):701-6; discu…
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psnet.ahrq.gov/issue/human-factors-focused-reporting-system-improving-care-quality-and-safety-hospital-wards
February 17, 2010 - Study
Human factors–focused reporting system for improving care quality and safety in hospital wards.
Citation Text:
Morag I, Gopher D, Spillinger A, et al. Human Factors–Focused Reporting System for Improving Care Quality and Safety in Hospital Wards. Hum Factors. 2012;54(2):195-213. …
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psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient-clinicians
July 20, 2022 - Study
Secure messaging use and wrong-patient ordering errors among inpatient clinicians.
Citation Text:
Lou SS, Lew D, Xia L, et al. Secure messaging use and wrong-patient ordering errors among inpatient clinicians. JAMA Netw Open. 2024;7(12):e2447797. doi:10.1001/jamanetworkopen.2024.47…
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psnet.ahrq.gov/issue/proactive-risk-assessment-surgical-site-infections-ambulatory-surgery-centers
April 13, 2022 - Study
Proactive risk assessment of surgical site infections in ambulatory surgery centers.
Citation Text:
Bish EK, Azadeh-Fard N, Steighner LA, et al. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers. J Patient Saf. 2014;13(2). doi:10.1097/pts.000000000…
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psnet.ahrq.gov/issue/how-patients-can-improve-accuracy-their-medical-records
July 20, 2022 - Study
How patients can improve the accuracy of their medical records.
Citation Text:
Dullabh P, Sondheimer N, Katsh E, et al. How Patients Can Improve the Accuracy of their Medical Records. eGEMs (Generating Evidence & Methods to improve patient outcomes). 2014;2(3). doi:10.13063/2327-92…
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psnet.ahrq.gov/issue/evaluation-measure-dx-resource-accelerate-diagnostic-safety-learning-and-improvement
February 07, 2024 - Study
Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement.
Citation Text:
Bradford A, Tran A, Ali KJ, et al. Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement. J Gen Intern Med. . 2024;Epub Oct 22. doi:…
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psnet.ahrq.gov/issue/artificial-intelligence-can-be-regulated-using-current-patient-safety-procedures-and
March 06, 2019 - Commentary
Artificial intelligence can be regulated using current patient safety procedures and infrastructure in hospitals.
Citation Text:
Fleisher LA, Economou-Zavlanos NJ. Artificial intelligence can be regulated using current patient safety procedures and infrastructure in hospitals.…
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hcup-us.ahrq.gov/tools_software.jsp
July 01, 2025 - Software Tools
HCUP software tools can be applied to HCUP and other administrative databases to systematically create new data elements from existing data, thereby enhancing a researcher's ability to conduct analyses.
Tools for ICD-10-CM/PCS
Designed for use with International Classification of Disea…
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psnet.ahrq.gov/issue/psychological-safety-communication-openness-nurse-job-outcomes-and-patient-safety-hospital
August 19, 2020 - Study
Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses.
Citation Text:
Cho H, Steege LM, Arsenault Knudsen ÉN. Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses. Res Nurs Health. …
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www.ahrq.gov/cpi/about/otherwebsites/cds-connect/index.html
June 01, 2019 - CDS Connect: Using Clinical Decision Support To Move Evidence Into Practice
Project Summary
CDS Connect is a key component of AHRQ’s recently launched initiative on clinical decision support (CDS) to move evidence into practice and to make CDS more patient centered. This initiative has four components:
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hcup-us.ahrq.gov/news/exhibit_booth/NASSBrochure_031220.pdf
March 18, 2020 - PowerPoint Presentation
What is the NASS?
The Nationwide Ambulatory Surgery Sample
(NASS) is part of the family of databases and
software tools developed for the Healthcare Cost
and Utilization Project (HCUP). The NASS
produces national estimates of major ambulatory
surgery encounters performed in hospital-owned
faci…