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psnet.ahrq.gov/node/46471/psn-pdf
March 20, 2018 - Diagnostic errors in primary care pediatrics: Project
RedDE.
March 20, 2018
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds.
2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
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psnet.ahrq.gov/node/45555/psn-pdf
June 15, 2017 - Variations in GPs' decisions to investigate suspected
lung cancer: a factorial experiment using multimedia
vignettes.
June 15, 2017
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung
cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf. 2017;26(6…
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psnet.ahrq.gov/node/43785/psn-pdf
May 01, 2015 - Evaluation of the effectiveness of a surgical checklist in
Medicare patients.
May 1, 2015
Reames BN, Scally CP, Thumma JR, et al. Evaluation of the Effectiveness of a Surgical Checklist in
Medicare Patients. Med Care. 2015;53(1):87-94. doi:10.1097/MLR.0000000000000277.
https://psnet.ahrq.gov/issue/evaluation-effec…
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psnet.ahrq.gov/node/37462/psn-pdf
January 06, 2017 - Medication errors associated with code situations in U.S.
hospitals: direct and collateral damage.
January 6, 2017
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S.
Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf. 2016;34(1):46-56.
doi:10.1016/…
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psnet.ahrq.gov/node/39302/psn-pdf
February 17, 2010 - Preoperative briefing in the operating room: shared
cognition, teamwork, and patient safety.
February 17, 2010
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork,
and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08-1732.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47524/psn-pdf
June 19, 2019 - Learning from patients' experiences related to diagnostic
errors is essential for progress in patient safety.
June 19, 2019
Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors
Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…
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psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
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January 17, 2012
A handbook developed by the …
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psnet.ahrq.gov/node/42081/psn-pdf
April 09, 2013 - Types and origins of diagnostic errors in primary care
settings.
April 9, 2013
Singh H, Giardina TD, Meyer AND, et al. Types and origins of diagnostic errors in primary care settings.
JAMA Intern Med. 2013;173(6):418-425. doi:10.1001/jamainternmed.2013.2777.
https://psnet.ahrq.gov/issue/types-and-origins-diagnosti…
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psnet.ahrq.gov/node/43773/psn-pdf
May 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million
Fewer Patient Harms: Interim Update on 2013 Annual
Hospital-Acquired Condition Rate and Estimates of Cost
Savings and Deaths Averted From 2010 to 2013.
May 1, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. …
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psnet.ahrq.gov/node/44925/psn-pdf
July 27, 2018 - Improving safety for hospitalized patients: much progress
but many challenges remain.
July 27, 2018
Kronick R, Arnold S, Brady J. Improving Safety for Hospitalized Patients: Much Progress but Many
Challenges Remain. JAMA. 2016;316(5):489-90. doi:10.1001/jama.2016.7887.
https://psnet.ahrq.gov/issue/improving-safety…
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psnet.ahrq.gov/node/46135/psn-pdf
July 11, 2017 - Two-state collaborative study of a multifaceted
intervention to decrease ventilator-associated events.
July 11, 2017
Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease
Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215.
doi:10.1097/CCM.0000000000…
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psnet.ahrq.gov/node/44034/psn-pdf
January 19, 2016 - Surgical checklist implementation project: the impact of
variable WHO checklist compliance on risk-adjusted
clinical outcomes after national implementation: a
longitudinal study.
January 19, 2016
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable
WHO Checklist C…
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psnet.ahrq.gov/issue/effect-rapid-response-system-patients-shock-time-treatment-and-mortality-during-5-years
October 19, 2022 - Study
Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years.
Citation Text:
Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care M…
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psnet.ahrq.gov/issue/drug-calculation-ability-qualified-paramedics-pilot-study
June 25, 2018 - Study
Drug calculation ability of qualified paramedics: a pilot study.
Citation Text:
Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006.
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psnet.ahrq.gov/issue/passing-baton-grounded-practical-theory-handoff-communication-between-multidisciplinary
November 16, 2022 - Study
Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings.
Citation Text:
Koenig CJ, Maguen S, Daley A, et al. Passing the baton: a grounded practical theory of handoff commu…
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psnet.ahrq.gov/issue/nature-and-causes-unintended-events-reported-10-internal-medicine-departments
August 17, 2016 - Study
The nature and causes of unintended events reported at 10 internal medicine departments.
Citation Text:
Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.109…
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psnet.ahrq.gov/issue/impact-stewardship-interventions-antiretroviral-medication-errors-urban-medical-center-three
February 10, 2016 - Study
Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study.
Citation Text:
Zucker J, Mittal J, Jen S-P, et al. Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center…
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psnet.ahrq.gov/issue/distractions-cardiac-catheterisation-laboratory-impact-cardiologists-and-patient-safety
June 07, 2023 - Study
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.
Citation Text:
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:…
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psnet.ahrq.gov/issue/using-rapid-response-system-provide-better-oversight-patient-care-processes
January 07, 2015 - Commentary
Using the rapid response system to provide better oversight of patient care processes.
Citation Text:
Moore MS, Howard SK, Lighthall GK. Using the rapid response system to provide better oversight of patient care processes. Jt Comm J Qual Patient Saf. 2007;33(11):695-8, 645.
…
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psnet.ahrq.gov/issue/risk-adverse-drug-events-neonates-treated-opioids-and-effect-bar-code-assisted-medication
May 21, 2009 - Study
Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.
Citation Text:
Morriss FH, Abramowitz PW, Nelson S, et al. Risk of adverse drug events in neonates treated with opioids and the effect of a bar-cod…