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psnet.ahrq.gov/issue/thematic-reviews-patient-safety-incidents-tool-systems-thinking-quality-improvement-report
January 15, 2020 - Commentary
Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.
Citation Text:
Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Qual. 2023;12(2):e002020. doi…
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psnet.ahrq.gov/issue/incidence-and-severity-adverse-events-affecting-patients-after-discharge-hospital
March 11, 2019 - Study
Classic
The incidence and severity of adverse events affecting patients after discharge from the hospital.
Citation Text:
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hos…
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psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - Study
Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems.
Citation Text:
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the a…
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-emergency-medicine-residencies-and-culture-safety
November 16, 2022 - Study
Morbidity and mortality conference in emergency medicine residencies and the culture of safety.
Citation Text:
Aaronson E, Wittels KA, Nadel ES, et al. Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety. West J Emerg Med. 2015;16(6):810-7…
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digital.ahrq.gov/ahrq-funded-projects/disseminating-and-implementing-medsmart-families-emergency-departments
September 30, 2024 - Disseminating and Implementing MedSMA℞T Families in Emergency Departments: A Randomized Control Trial to Assess Effectiveness of an Evidence-Based Gaming Intervention to Reduce Opioid Misuse
Project Description
Implementing a mobile game-based tool in emergency departments (EDs…
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psnet.ahrq.gov/issue/invisible-disability-communication-patient-safety-and-dual-sensory-impairment-older-persons
July 01, 2019 - Commentary
An invisible disability: communication, patient safety and dual sensory impairment in older persons.
Citation Text:
Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual sensory impairment in older persons. J Adv Nurs. 2024;Epub …
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psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0
July 31, 2024 - Review
Medication administration in aged care facilities: a mixed-methods systematic review.
Citation Text:
Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318.
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psnet.ahrq.gov/issue/optimizing-pediatric-patient-safety-emergency-care-setting
March 15, 2023 - Organizational Policy/Guidelines
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
Citation Text:
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
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psnet.ahrq.gov/issue/perspectives-patient-and-family-engagement-reduction-harm-forgotten-voice
December 01, 2011 - Study
Perspectives on patient and family engagement with reduction in harm: the forgotten voice.
Citation Text:
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79. doi:10.1…
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psnet.ahrq.gov/issue/understanding-factors-influencing-safety-and-team-functionality-operative-vaginal-birth
September 01, 2016 - Study
Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study.
Citation Text:
Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at operat…
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psnet.ahrq.gov/issue/improving-maternal-safety-scale-mentor-model-collaborative-improvement
March 31, 2021 - Study
Improving maternal safety at scale with the mentor model of collaborative improvement.
Citation Text:
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259. doi:10.10…
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integrationacademy.ahrq.gov/news-and-events/news/opioid-use-disorder-resources-2019-updates
October 04, 2019 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/case-based-simulation-empowering-pediatric-residents-communicate-about-diagnostic-uncertainty
November 27, 2017 - Study
Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty.
Citation Text:
Olson ME, Borman-Shoap E, Mathias K, et al. Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty. Diagnosis (Berl). 2018;5(4)…
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psnet.ahrq.gov/issue/evaluation-and-accurate-diagnoses-pediatric-diseases-using-artificial-intelligence
April 15, 2020 - Study
Classic
Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence.
Citation Text:
Liang H, Tsui BY, Ni H, et al. Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence. Nat Med. 2019;25(3):433-438.…
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psnet.ahrq.gov/issue/foundational-science-learning-health-systems
June 26, 2019 - Commentary
The foundational science of learning health systems.
Citation Text:
Kilbourne AM, Borsky AE, O'Brien RW, et al. The foundational science of learning health systems. Health Serv Res. 2024;59(6):e14374. doi:10.1111/1475-6773.14374.
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/development-icu-safety-reporting-system
May 27, 2011 - Study
Development of the ICU safety reporting system.
Citation Text:
Development of the ICU safety reporting system. Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
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psnet.ahrq.gov/issue/guidelines-human-factors-critical-situations-2023
November 29, 2023 - Organizational Policy/Guidelines
Guidelines on Human Factors in Critical Situations 2023.
Citation Text:
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
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psnet.ahrq.gov/issue/elephant-patient-safety-what-you-see-depends-how-you-look
June 22, 2022 - Commentary
Classic
The elephant of patient safety: what you see depends on how you look.
Citation Text:
Shojania KG. The elephant of patient safety: what you see depends on how you look. Jt Comm J Qual Patient Saf. 2010;36(9):399-401.
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integrationacademy.ahrq.gov/news-and-events/news/nih-heal-initiative-overdose-resources-announced
February 19, 2025 - An official website of the Department of Health & Human Services
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