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psnet.ahrq.gov/node/41437/psn-pdf
January 03, 2017 - Making the transition to nursing bedside shift reports.
January 3, 2017
Wakefield DS, Ragan R, Brandt J, et al. Making the transition to nursing bedside shift reports. Jt Comm J
Qual Patient Saf. 2012;38(6):243-53.
https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports
Efforts to improve comm…
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psnet.ahrq.gov/node/42040/psn-pdf
September 28, 2016 - The intended and unintended consequences of
communication systems on general internal medicine
inpatient care delivery: a prospective observational case
study of five teaching hospitals.
September 28, 2016
Wu RC, Lo V, Morra D, et al. The intended and unintended consequences of communication systems on
general in…
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psnet.ahrq.gov/node/35855/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Third Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO: HealthGrades; 2006.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-third-annual-patient-safety-american-hospitals-
study
This third annual report on the safety of hospitalized Medicare patien…
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psnet.ahrq.gov/node/851351/psn-pdf
July 12, 2023 - Healthcare workers' experiences of patient safety in the
intensive care unit during the COVID-19 pandemic: a
multicentre qualitative study.
July 12, 2023
Berggren K, Ekstedt M, Joelsson?Alm E, et al. Healthcare workers' experiences of patient safety in the
intensive care unit during the COVID?19 pandemic: a multic…
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psnet.ahrq.gov/node/44114/psn-pdf
September 27, 2016 - Advancing the future of patient safety in oncology:
implications of patient safety education on cancer care
delivery.
September 27, 2016
James TA, Goedde M, Bertsch T, et al. Advancing the Future of Patient Safety in Oncology: Implications of
Patient Safety Education on Cancer Care Delivery. J Cancer Educ. 2016;31…
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psnet.ahrq.gov/node/37873/psn-pdf
June 16, 2009 - Dropping the baton: a qualitative analysis of failures
during the transition from emergency department to
inpatient care.
June 16, 2009
Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the
transition from emergency department to inpatient care. Ann Emerg Med. …
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psnet.ahrq.gov/node/46652/psn-pdf
July 14, 2018 - The effects of crew resource management on teamwork
and safety climate at Veterans Health Administration
facilities.
July 14, 2018
Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource management on teamwork and
safety climate at Veterans Health Administration facilities. J Healthc Risk Manag. 2018;…
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psnet.ahrq.gov/node/39800/psn-pdf
January 19, 2011 - Medication errors in paediatric outpatients.
January 19, 2011
Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf.
2010;19(6). doi:10.1136/qshc.2008.031179.
https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
Pediatric medication errors are common …
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psnet.ahrq.gov/node/865484/psn-pdf
April 03, 2024 - Communication of incidental imaging findings on
inpatient discharge summaries after implementation of
electronic health record notification system.
April 3, 2024
Mattay G, Mallikarjun K, Grow P, et al. Communication of incidental imaging findings on inpatient discharge
summaries after implementation of electronic …
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psnet.ahrq.gov/node/41925/psn-pdf
November 26, 2014 - Medication reconciliation accuracy and patient
understanding of intended medication changes on
hospital discharge.
November 26, 2014
Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding
of intended medication changes on hospital discharge. J Gen Intern Med. 2012;2…
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psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - Revealing and resolving patient safety defects: the impact
of leadership WalkRounds on frontline caregiver
assessments of patient safety.
June 16, 2011
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of
leadership WalkRounds on frontline caregiver assessments of p…
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psnet.ahrq.gov/node/45891/psn-pdf
October 11, 2017 - Extent of diagnostic agreement among medical referrals.
October 11, 2017
Van Such M, Lohr R, Beckman T, et al. Extent of diagnostic agreement among medical referrals. J Eval
Clin Pract. 2017;23(4):870-874. doi:10.1111/jep.12747.
https://psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals
Diagn…
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psnet.ahrq.gov/node/36308/psn-pdf
January 05, 2017 - A trigger tool to identify adverse events in the intensive
care unit.
January 5, 2017
Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care
Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s1553-
7250(06)32076-4.
https://…
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psnet.ahrq.gov/node/836964/psn-pdf
April 20, 2022 - Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a
cohort study using trigger tool methodology.
April 20, 2022
Nowak B, Schwendimann R, Lyrer P, et al. Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a …
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psnet.ahrq.gov/node/60812/psn-pdf
January 01, 2021 - A clinical pharmacist-led integrated approach for
evaluation of medication errors among medical intensive
care unit patients.
August 19, 2020
Aghili M, Neelathahalli Kasturirangan M. A clinical pharmacist-led integrated approach for evaluation of
medication errors among medical intensive care unit patients. JBI Ev…
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psnet.ahrq.gov/node/35572/psn-pdf
February 03, 2011 - The long road to patient safety: a status report on patient
safety systems.
February 3, 2011
Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety
systems. JAMA. 2005;294(22):2858-65.
https://psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-s…
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psnet.ahrq.gov/node/836953/psn-pdf
April 20, 2022 - Systems-level factors affecting registered nurses during
care of women in labor experiencing clinical deterioration.
April 20, 2022
Bernstein SL, Catchpole K, Kelechi TJ, et al. Systems-level factors affecting registered nurses during care
of women in labor experiencing clinical deterioration. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/848039/psn-pdf
April 26, 2023 - Use of the revised second victim experience and support
tool to examine second victim experiences of respiratory
therapists.
April 26, 2023
Allender EA, Bottema SM, Bosley CL, et al. Use of the revised second victim experience and support tool
to examine second victim experiences of respiratory therapists. Respir …
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psnet.ahrq.gov/node/37690/psn-pdf
April 16, 2008 - How willing are patients to question healthcare staff on
issues related to the quality and safety of their
healthcare? An exploratory study.
April 16, 2008
Davis R, Koutantji M, Vincent C. How willing are patients to question healthcare staff on issues related to
the quality and safety of their healthcare? An expl…
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psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
August 12, 2020 - Newspaper/Magazine Article
Medication errors in the emergency department: need for pharmacy involvement?
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April 16, 2018
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