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psnet.ahrq.gov/node/41496/psn-pdf
December 21, 2014 - Hospital-based medication reconciliation practices: a
systematic review.
December 21, 2014
Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a
systematic review. Arch Intern Med. 2012;172(14):1057-69. doi:10.1001/archinternmed.2012.2246.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/838010/psn-pdf
September 07, 2022 - Effect of different interventions to help primary care
clinicians avoid unsafe opioid prescribing in opioid-naive
patients with acute noncancer pain: a cluster randomized
clinical trial.
September 7, 2022
Kraemer KL, Althouse AD, Salay M, et al. Effect of different interventions to help primary care clinicians
av…
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psnet.ahrq.gov/node/44575/psn-pdf
January 22, 2016 - A narrative review of high-quality literature on the effects
of resident duty hours reforms.
January 22, 2016
Lin H, Lin E, Auditore S, et al. A Narrative Review of High-Quality Literature on the Effects of Resident Duty
Hours Reforms. Acad Med. 2016;91(1):140-50. doi:10.1097/ACM.0000000000000937.
https://psnet.ah…
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psnet.ahrq.gov/node/60680/psn-pdf
July 15, 2020 - Contributing factors for pediatric ambulatory diagnostic
process errors: Project RedDE.
July 15, 2020
Dadlez NM, Adelman JS, Bundy DG, et al. Contributing factors for pediatric ambulatory diagnostic process
errors: Project RedDE. Ped Qual Saf. 2020;5(3):e299-e305. doi:10.1097/pq9.0000000000000299.
https://psnet.ah…
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psnet.ahrq.gov/node/840484/psn-pdf
November 30, 2022 - Interdisciplinary collaboration across secondary and
primary care to improve medication safety in the elderly
(The IMMENSE study) - a randomized controlled trial.
November 30, 2022
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and
primary care to improve medication …
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psnet.ahrq.gov/node/39748/psn-pdf
August 11, 2010 - Information transfer and communication in surgery: a
systematic review.
August 11, 2010
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review.
Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
https://psnet.ahrq.gov/issue/information-transfer-and-comm…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - excitability, and thereby mimicking the neurodepressant effect of alcohol. 12,13
• This mechanism reduces
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/866848/psn-pdf
September 25, 2024 - In Conversation with Eric Thomas about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce
Preventable Harms – Point, Counterpoint, and Areas of Agreement. …
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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September 23, 2024
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April 01, 2003 - The 2-Week Itch
April 1, 2003
Cohen MR. The 2-Week Itch. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/2-week-itch
The Case
A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new
urticaria. She received a handwritten prescription for Zyrtec and Atarax.
The ha…
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psnet.ahrq.gov/issue/medication-errors-hiv-infected-hospitalized-patients-pharmacists-impact
November 16, 2022 - Study
Medication errors in HIV-infected hospitalized patients: a pharmacist's impact.
Citation Text:
Eginger KH, Yarborough LL, Inge LDV, et al. Medication errors in HIV-infected hospitalized patients: a pharmacist's impact. Ann Pharmacother. 2013;47(7-8):953-60. doi:10.1345/aph.1R773.…
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psnet.ahrq.gov/issue/disclosing-errors-and-adverse-events-intensive-care-unit
February 17, 2017 - Study
Disclosing errors and adverse events in the intensive care unit.
Citation Text:
Boyle DJ, O'Connell D, Platt FW, et al. Disclosing errors and adverse events in the intensive care unit. Crit Care Med. 2006;34(5):1532-7.
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psnet.ahrq.gov/issue/rapid-response-systems-identification-and-management-prearrest-state
May 18, 2022 - Review
Rapid response systems: identification and management of the "prearrest state."
Citation Text:
McCurdy MT, Wood SL. Rapid response systems: identification and management of the "prearrest state". Emerg Med Clin North Am. 2012;30(1):141-52. doi:10.1016/j.emc.2011.09.012.
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psnet.ahrq.gov/issue/high-reliability-pediatric-heart-centers-always-working-toward-getting-better
September 18, 2024 - Commentary
High reliability pediatric heart centers: always working toward getting better.
Citation Text:
Torzone A, Birely A. High reliability pediatric heart centers: always working toward getting better. Curr Opin Cardiol. 2024;39(4):356-363. doi:10.1097/hco.0000000000001143.
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psnet.ahrq.gov/issue/socio-technical-systems-approach-studying-interruptions-understanding-interrupters
October 03, 2013 - Study
A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective.
Citation Text:
Rivera J. A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. Appl Ergon. 2014;45(3):747-56. doi:10.1016/…
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/patients-politicians-cognitive-engineering-view-patient-safety
January 29, 2020 - Commentary
From patients to politicians: a cognitive engineering view of patient safety.
Citation Text:
Vicente KJ. From patients to politicians: a cognitive engineering view of patient safety. Qual Saf Health Care. 2002;11(4):302-4.
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