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psnet.ahrq.gov/issue/improving-patient-safety-icu-prospective-identification-missing-safety-barriers-using-bow-tie
February 14, 2024 - Study
Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.
Citation Text:
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification o…
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psnet.ahrq.gov/issue/why-do-healthcare-professionals-fail-escalate-early-warning-system-ews-protocol-qualitative
August 25, 2021 - Review
Emerging Classic
Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation.
Citation Text:
O’Neill SM, Clyne B, Bell M, et al. Why do h…
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psnet.ahrq.gov/issue/identifying-and-reducing-medication-errors-psychiatry-creating-culture-safety-through-use
September 27, 2017 - Study
Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.
Citation Text:
Jayaram G, Doyle D, Steinwachs D, et al. Identifying and reducing medication errors in psychiatry: creating a culture of sa…
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psnet.ahrq.gov/issue/characterising-complexity-medication-safety-using-human-factors-approach-observational-study
March 15, 2017 - Study
Classic
Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.
Citation Text:
Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety us…
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psnet.ahrq.gov/issue/electronic-trigger-based-care-escalation-identify-preventable-adverse-events-hospitalised
September 28, 2016 - Study
Classic
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Citation Text:
Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable adverse even…
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psnet.ahrq.gov/issue/improving-medication-reconciliation-comprehensive-evaluation-veterans-affairs-skilled-nursing
May 19, 2021 - Study
Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.
Citation Text:
Baughman AW, Triantafylidis LK, O'Neil N, et al. Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing …
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psnet.ahrq.gov/issue/adverse-medication-events-related-hospitalization-united-states-comparison-between-adults
February 02, 2022 - Study
Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without.
Citation Text:
Erickson SR, Kamdar N, Wu C-H. Adverse Medication Events Related to Hospitalization in the Unite…
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psnet.ahrq.gov/issue/measuring-patient-safety-primary-care-development-and-validation-patient-reported-experiences
April 25, 2018 - Study
Measuring patient safety in primary care: the development and validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC).
Citation Text:
Ricci-Cabello I, Avery A, Reeves D, et al. Measuring Patient Safety in Primary Care: The Development and …
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psnet.ahrq.gov/issue/patient-safety-era-80-hour-workweek
March 09, 2019 - Study
Patient safety in the era of the 80-hour workweek.
Citation Text:
Shelton J, Kummerow K, Phillips S, et al. Patient safety in the era of the 80-hour workweek. J Surg Educ. 2014;71(4):551-9. doi:10.1016/j.jsurg.2013.12.011.
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psnet.ahrq.gov/issue/profit-long-term-care-homes-and-risk-covid-19-outbreaks-and-resident-deaths
October 28, 2020 - Study
For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.
Citation Text:
Stall NM, Jones A, Brown KA, et al. For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths. CMAJ. 2020;192(33):e946-e955 . doi:10.1503/cmaj.201197.…
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psnet.ahrq.gov/issue/never-events-uk-general-practice-survey-views-general-practitioners-their-frequency-and
June 30, 2021 - Study
Never events in UK general practice: A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach
Citation Text:
Stocks SJ, Alam R, Bowie P, et al. Never Events in UK General Practice: A Survey of the Views of General Practiti…
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psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
August 24, 2022 - Study
Emerging Classic
Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare.
Citation Text:
Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality measurement on n…
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psnet.ahrq.gov/issue/strategies-improving-patient-safety-culture-hospitals-systematic-review
February 14, 2017 - Review
Strategies for improving patient safety culture in hospitals: a systematic review.
Citation Text:
Morello RT, Lowthian JA, Barker AL, et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2013;22(1):11-8. doi:10.1136/bmjqs-2011-0…
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psnet.ahrq.gov/issue/association-between-leapfrog-safe-practices-score-and-hospital-mortality-major-surgery
September 29, 2017 - Study
Association between Leapfrog safe practices score and hospital mortality in major surgery.
Citation Text:
Qian F, Lustik SJ, Diachun CA, et al. Association between Leapfrog safe practices score and hospital mortality in major surgery. Med Care. 2011;49(12):1082-1088. doi:10.1097/…
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psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-patient-safety-and-magnet-designation-united
October 09, 2019 - Study
Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States.
Citation Text:
Hamadi H, Borkar SR, DHA LRM, et al. Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. J Patient Sa…
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psnet.ahrq.gov/issue/multifaceted-risk-management-program-improve-reporting-rate-patient-safety-incidents-primary
August 24, 2022 - Study
A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial.
Citation Text:
Chanelière M, Buchet-Poyau K, Keriel-Gascou M, et al. A multifaceted risk management program to improve the report…
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psnet.ahrq.gov/issue/adaption-trigger-tool-identify-harmful-incidents-no-harm-incidents-and-near-misses
May 25, 2022 - Study
Adaption of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care of children.
Citation Text:
Packendorff N, Magnusson C, Axelsson C, et al. Adaption of a trigger tool to identify harmful incidents, no harm incidents, and nea…
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psnet.ahrq.gov/issue/hospital-leadership-and-quality-improvement-rhetoric-versus-reality
May 07, 2014 - Study
Hospital leadership and quality improvement: rhetoric versus reality.
Citation Text:
Levey S, Vaughn T, Koepke M, et al. Hospital Leadership and Quality Improvement. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e3180311256.
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psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease-2019-pandemic
May 25, 2022 - Commentary
A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic.
Citation Text:
Pollock BD, Dykhoff HJ, Breeher LE, et al. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Mayo Clin Proc …
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psnet.ahrq.gov/issue/reported-clinical-incidents-children-intellectual-disability-qualitative-analysis
March 16, 2022 - Study
Reported clinical incidents of children with intellectual disability: a qualitative analysis.
Citation Text:
Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with intellectual disability: a qualitative analysis. Dev Med Child Neurol. 2022;64(11):1359-1365. …