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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/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/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/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/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/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/847717/psn-pdf
April 19, 2023 - Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19
pandemic: a "zero harm" approach.
April 19, 2023
Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19 pan…
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psnet.ahrq.gov/node/46612/psn-pdf
February 22, 2018 - Influencing organisational culture to improve hospital
performance in care of patients with acute myocardial
infarction: a mixed-methods intervention study.
February 22, 2018
Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital
performance in care of patients with acute …
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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/39730/psn-pdf
December 21, 2014 - Surgical case listing accuracy: failure analysis at a high-
volume academic medical center.
December 21, 2014
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume
academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archsurg.2010.112.
https://psnet.a…
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psnet.ahrq.gov/node/38553/psn-pdf
April 14, 2010 - The effect of computerized physician order entry on
medication prescription errors and clinical outcome in
pediatric and intensive care: a systematic review.
April 14, 2010
van Rosse F, Maat B, Rademaker CMA, et al. The effect of computerized physician order entry on
medication prescription errors and clinical out…
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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/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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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/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/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/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process.
Citation Text:
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…
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psnet.ahrq.gov/issue/cluster-randomized-trial-two-implementation-strategies-deliver-audit-and-feedback-equipped
September 01, 2018 - Study
A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.
Citation Text:
Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…
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psnet.ahrq.gov/issue/preventing-potentially-inappropriate-medication-use-hospitalized-older-patients-computerized
November 16, 2022 - Study
Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.
Citation Text:
Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in hospitalized older patients wi…