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psnet.ahrq.gov/issue/effect-computerized-provider-order-entry-systems-clinical-care-and-work-processes-emergency
May 25, 2011 - Review
The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.
Citation Text:
Georgiou A, Prgomet M, Paoloni R, et al. The effect of computerized provider order entry syst…
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psnet.ahrq.gov/issue/costs-intravenous-adverse-drug-events-academic-and-nonacademic-intensive-care-units
August 11, 2021 - Study
Costs of intravenous adverse drug events in academic and nonacademic intensive care units.
Citation Text:
Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous adverse drug events in academic and nonacademic intensive care units. Med Care. 2009;46(1):17-24. doi:10.1097/m…
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - Study
Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?
Citation Text:
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
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psnet.ahrq.gov/issue/assessment-health-information-technology-related-outpatient-diagnostic-delays-us-veterans
June 24, 2020 - Study
Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.
Citation Text:
Powell L, Sittig DF, Chrouser K, et al. Assessment of health information techno…
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - Study
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.
Citation Text:
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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psnet.ahrq.gov/issue/qualitative-study-speaking-out-about-patient-safety-concerns-intensive-care-units
August 21, 2013 - Study
A qualitative study of speaking out about patient safety concerns in intensive care units.
Citation Text:
Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient safety concerns in intensive care units. Soc Sci Med. 2017;193:8-15. doi:10.1016/j.socscim…
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psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
June 29, 2011 - Study
Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.
Citation Text:
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
February 06, 2019 - Study
Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.
Citation Text:
Morisawa T, Saitoh M, Otsuka S, et al. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients…
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/issue/association-surgical-task-during-training-team-skill-acquisition-among-surgical-residents
March 12, 2025 - Study
Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.
Citation Text:
Sparks JL, Crouch DL, Sobba K, et al. Association of a Surgical Task During Training With Team Skill Acquisition…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/node/43573/psn-pdf
October 01, 2014 - Effective communication with primary care providers.
October 1, 2014
Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679.
doi:10.1016/j.pcl.2014.04.004.
https://psnet.ahrq.gov/issue/effective-communication-primary-care-providers
Highlighting how the disconnect be…
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psnet.ahrq.gov/node/865683/psn-pdf
Our stubborn quest for diagnostic certainty.
June 1, 1989
Kassirer JP. Our stubborn quest for diagnostic certainty. N Engl J Med. 1989;320(22):1489-1491.
doi:10.1056/nejm198906013202211.
https://psnet.ahrq.gov/issue/our-stubborn-quest-diagnostic-certainty
The topic of uncertainty has been largely neglected in the …
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psnet.ahrq.gov/node/45334/psn-pdf
September 07, 2016 - Why 'Universal Precautions' are needed for medication
lists.
September 7, 2016
Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2.
doi:10.1136/bmjqs-2015-005116.
https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists
Despite the support…
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psnet.ahrq.gov/node/41373/psn-pdf
May 16, 2012 - Self-reported violations during medication administration
in two paediatric hospitals.
May 16, 2012
Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two
paediatric hospitals. BMJ Qual Saf. 2012;21(5):408-15. doi:10.1136/bmjqs-2011-000007.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/45968/psn-pdf
October 24, 2024 - State of Care.
October 24, 2024
Newcastle Upon Tyne, UK: Care Quality Commission; October 2024.
https://psnet.ahrq.gov/issue/state-care
This website provides access to an annual report that summarizes National Health Service hospital and
social care performance across a range of care quality metrics at both the tr…
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psnet.ahrq.gov/node/853445/psn-pdf
December 15, 2022 - Jake Tapper shares harrowing story of daughter's near-
fatal misdiagnosis.
December 15, 2022
CNN. December 15, 2022.
https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis
Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’…
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psnet.ahrq.gov/node/60538/psn-pdf
May 27, 2020 - Diagnostic Safety Toolkit.
May 27, 2020
Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital
Association. May 2020.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit
Effective communication is an important component of diagnostic accuracy. Shaped with data co…
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psnet.ahrq.gov/node/43734/psn-pdf
January 21, 2015 - Explicit and Standardized Prescription Medicine
Instructions.
January 21, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions
Standardization has been embraced as a strategy to improve health litera…