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psnet.ahrq.gov/node/40654/psn-pdf
January 01, 2012 - The computerized rounding report: implementation of a
model system to support transitions of care.
December 15, 2011
Wohlauer M, Rove KO, Pshak TJ, et al. The computerized rounding report: implementation of a model
system to support transitions of care. J Surg Res. 2012;172(1):11-7. doi:10.1016/j.jss.2011.04.015.
…
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psnet.ahrq.gov/node/44330/psn-pdf
September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop
Summary.
September 2, 2015
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of
Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN:
9780309371544.
https://psnet.…
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psnet.ahrq.gov/node/44140/psn-pdf
July 15, 2015 - Openness and Honesty When Things Go Wrong: the
Professional Duty of Candour.
July 15, 2015
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
Open and honest discussion with patie…
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psnet.ahrq.gov/node/44620/psn-pdf
November 04, 2015 - Laboratory testing in general practice: a patient safety
blind spot.
November 4, 2015
Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf.
2015;24(11):667-70. doi:10.1136/bmjqs-2015-004644.
https://psnet.ahrq.gov/issue/laboratory-testing-general-practice-patient-safety-blind…
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psnet.ahrq.gov/node/46764/psn-pdf
March 28, 2018 - The Report of the Short Life Working Group on Reducing
Medication-related Harm.
March 28, 2018
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm
Medication errors are a prominent chal…
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psnet.ahrq.gov/node/48140/psn-pdf
July 31, 2019 - Impact of critical event checklists on anaesthetist
performance in simulated operating theatre emergencies.
July 31, 2019
Siddiqui A, Ng E, Burrows C, et al. Impact of Critical Event Checklists on Anaesthetist Performance in
Simulated Operating Theatre Emergencies. Cureus. 2019;11(4):e4376. doi:10.7759/cureus.4376.…
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psnet.ahrq.gov/node/44002/psn-pdf
March 25, 2015 - Preventing medication errors in transitions of care: a
patient case approach.
March 25, 2015
Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case
approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509.
https://psnet.ahrq.gov/issue/prevent…
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psnet.ahrq.gov/node/40676/psn-pdf
November 26, 2014 - Cost implications of ACGME's 2011 changes to resident
duty hours and the training environment.
November 26, 2014
Nuckols TK, Escarce JJ. Cost implications of ACGME's 2011 changes to resident duty hours and the
training environment. J Gen Intern Med. 2012;27(2):241-9. doi:10.1007/s11606-011-1775-9.
https://psnet.ah…
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psnet.ahrq.gov/node/50785/psn-pdf
January 08, 2020 - Moving Measurement into Action: Global Principles for
Measuring Patient Safety.
January 8, 2020
IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar;
December 2019.
https://psnet.ahrq.gov/issue/moving-measurement-action-global-principles-measuring-patient-safety
Me…
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psnet.ahrq.gov/node/841200/psn-pdf
December 07, 2022 - Preventing errors when preparing and administering
medications via enteral feeding tubes.
December 7, 2022
ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).
https://psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-
feeding-tubes
Enteral feeding …
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psnet.ahrq.gov/node/43946/psn-pdf
May 28, 2015 - Development and measurement of perioperative patient
safety indicators.
May 28, 2015
Emond YE, Stienen JJ, Wollersheim HC, et al. Development and measurement of perioperative patient
safety indicators. Br J Anaesth. 2015;114(6):963-72. doi:10.1093/bja/aeu561.
https://psnet.ahrq.gov/issue/development-and-measuremen…
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psnet.ahrq.gov/node/44557/psn-pdf
November 20, 2015 - Reforming the Veterans Health Administration—beyond
palliation of symptoms.
November 20, 2015
Giroir BP, Wilensky GR. Reforming the Veterans Health Administration--Beyond Palliation of Symptoms. N
Engl J Med. 2015;373(18):1693-5. doi:10.1056/NEJMp1511438.
https://psnet.ahrq.gov/issue/reforming-veterans-health-admi…
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www.ahrq.gov/takeheart/assessing/summary/index.html
August 01, 2023 - Implementing PCOR To Increase Referral, Enrollment, and Retention in Cardiac Rehabilitation Through Automatic Referral With Care Coordination
Final Evaluation Report: Executive Summary
About the Resource
TAKEheart was conducted between April 2019 and December 2022 by Abt Associates (Abt) and its…
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psnet.ahrq.gov/node/839825/psn-pdf
November 09, 2022 - Preventing medication errors in pediatric anesthesia: a
systematic scoping review.
November 9, 2022
Shawahna R, Jaber M, Jumaa E, et al. Preventing medication errors in pediatric anesthesia: a systematic
scoping review. J Patient Saf. 2022;18(7):e1047-e1060. doi:10.1097/pts.0000000000001019.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41718/psn-pdf
October 03, 2012 - Duty hours, quality of care, and patient safety: general
surgery resident perceptions.
October 3, 2012
Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: general surgery resident
perceptions. J Am Coll Surg. 2012;215(1):70-7; discussion 77-9. doi:10.1016/j.jamcollsurg.2012.02.010.
https…
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psnet.ahrq.gov/node/47101/psn-pdf
December 21, 2018 - Education and reporting of diagnostic errors among
physicians in internal medicine training programs.
December 21, 2018
Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians
in Internal Medicine Training Programs. JAMA Intern Med. 2018;178(11):1548-1549.
doi:10.1001/ja…
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psnet.ahrq.gov/node/46711/psn-pdf
July 01, 2019 - The STOP Measure. Safe and Transparent Opioid
Prescribing to Promote Patient Safety and Reduced Risk
of Opioid Misuse.
July 1, 2019
Washington, DC: America's Health Insurance Plans; 2019.
https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety-
and-reduced-risk
Gu…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
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psnet.ahrq.gov/node/74196/psn-pdf
December 15, 2021 - Adverse glycemic events and critical emergencies.
December 15, 2021
ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.
https://psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies
Insulin is a high-alert medication that requires extra attention to safely manage blood sugar …
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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…