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psnet.ahrq.gov/issue/web-based-incident-reporting-system-and-multidisciplinary-collaborative-projects-patient
October 27, 2010 - Study
A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital.
Citation Text:
Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a …
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psnet.ahrq.gov/issue/quality-and-health-system-becoming-high-reliability-organization
November 16, 2022 - Review
Quality and the health system: becoming a high reliability organization.
Citation Text:
Gaw M, Rosinia F, Diller T. Quality and the health system: becoming a high reliability organization. Anesthesiol Clin. 2018;36(2):217-226. doi:10.1016/j.anclin.2018.01.010.
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psnet.ahrq.gov/issue/medication-injection-safety-knowledge-and-practices-among-anesthesiologists-new-york-state
August 25, 2021 - Study
Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011.
Citation Text:
Gounder P, Beers R, Bornschlegel K, et al. Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011. J Clin Anesth. 2013;25(7)…
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psnet.ahrq.gov/issue/practice-gaps-patient-safety-among-dermatology-residents-and-their-teachers-survey-study
August 19, 2009 - Study
Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents.
Citation Text:
Swary JH, Stratman EJ. Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents. JA…
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psnet.ahrq.gov/issue/getting-underuse-interpreters-resident-physicians
February 21, 2018 - Study
Getting by: underuse of interpreters by resident physicians.
Citation Text:
Diamond LC, Schenker Y, Curry LA, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62. doi:10.1007/s11606-008-0875-7.
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psnet.ahrq.gov/issue/mental-models-basic-concept-human-factors-design-infection-prevention
April 26, 2017 - Commentary
Mental models: a basic concept for human factors design in infection prevention.
Citation Text:
Sax H, Clack L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect. 2015;89(4):335-9. doi:10.1016/j.jhin.2014.12.008.
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psnet.ahrq.gov/issue/work-overload-related-increased-risk-error-during-chemotherapy-preparation
June 30, 2011 - Study
Work overload is related to increased risk of error during chemotherapy preparation.
Citation Text:
Carrez L, Bouchoud L, Fleury S, et al. Work overload is related to increased risk of error during chemotherapy preparation. J Oncol Pharm Pract. 2019;25(6):1456-1466. doi:10.1177/107…
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psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
May 26, 2011 - Study
Current approaches to punitive action for medication errors by boards of pharmacy.
Citation Text:
Holdsworth M, Wittstrom K, Yeitrakis T. Current approaches to punitive action for medication errors by boards of pharmacy. Ann Pharmacother. 2013;47(4):475-81. doi:10.1345/aph.1R668. …
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psnet.ahrq.gov/issue/there-vulnerable-group-we-must-not-leave-behind-our-response-covid-19-people-who-are
October 05, 2022 - Newspaper/Magazine Article
There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on illicit drugs.
Citation Text:
Guirguis A. There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on…
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psnet.ahrq.gov/issue/maximizing-student-potential-lessons-pharmacy-programs-patient-safety-movement
October 23, 2024 - Commentary
Maximizing student potential: lessons for pharmacy programs from the patient safety movement.
Citation Text:
Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the patient safety movement. Explor Res Clin Soc Pharm. 2023;9:1002…
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psnet.ahrq.gov/issue/excess-cost-and-length-stay-associated-voluntary-patient-safety-event-reports-hospitals
October 19, 2022 - Study
Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.
Citation Text:
Paradis AR, Stewart VT, Bayley KB, et al. Excess Cost and Length of Stay Associated With Voluntary Patient Safety Event Reports in Hospitals. American Journal of M…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
June 02, 2025 - QAPI Leadership Rounding Guide
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse
managers) are out in the building with staff and residents, t…
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psnet.ahrq.gov/issue/measuring-improve-medication-reconciliation-large-subspecialty-outpatient-practice
February 02, 2011 - Study
Measuring to improve medication reconciliation in a large subspecialty outpatient practice.
Citation Text:
Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-2…
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psnet.ahrq.gov/issue/antibiotic-timing-and-errors-diagnosing-pneumonia
March 20, 2024 - Study
Antibiotic timing and errors in diagnosing pneumonia.
Citation Text:
Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. 2008;168(4):351-6. doi:10.1001/archinternmed.2007.84.
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psnet.ahrq.gov/issue/peer-support-anesthesia-turning-war-stories-wellness
July 13, 2010 - Review
Peer support in anesthesia: turning war stories into wellness.
Citation Text:
Vinson AE, Randel G. Peer support in anesthesia: turning war stories into wellness. Curr Opin Anaesthesiol. 2018;31(3):382-387. doi:10.1097/ACO.0000000000000591.
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psnet.ahrq.gov/issue/simulation-and-diagnostic-process-pilot-study-trauma-and-rapid-response-teams
July 16, 2015 - Study
Simulation and the diagnostic process: a pilot study of trauma and rapid response teams.
Citation Text:
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/…
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psnet.ahrq.gov/issue/medical-errors-and-consequent-adverse-events-critically-ill-surgical-patients-tertiary-care
December 22, 2010 - Study
Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi.
Citation Text:
Kumar S, Chaudhary S. Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospita…
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psnet.ahrq.gov/issue/changes-practice-and-organisation-surrounding-blood-transfusion-nhs-trusts-england-1995-2005
August 04, 2021 - Study
Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.
Citation Text:
Taylor CJC, Murphy MF, Lowe D, et al. Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005. Qual Saf Health Care. 2…
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psnet.ahrq.gov/issue/deficits-discharge-documentation-patients-transferred-rehabilitation-facilities
October 28, 2009 - Study
Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.
Citation Text:
Gandara E, Moniz TT, Ungar J, et al. Deficits in discharge documentation in patients transferred to rehabilitation facilit…
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psnet.ahrq.gov/issue/poor-state-health-care-quality-us-malpractice-liability-part-problem-or-part-solution
March 01, 2023 - Review
The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution?
Citation Text:
Hyman DA, Silver C. The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution? Co…