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psnet.ahrq.gov/node/60725/psn-pdf
July 29, 2020 - The tradeoffs between safety and alert fatigue: data from
a national evaluation of hospital medication-related
clinical decision support.
July 29, 2020
Co Z, Holmgren AJ, Classen DC, et al. The tradeoffs between safety and alert fatigue: data from a national
evaluation of hospital medication-related clinical decis…
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psnet.ahrq.gov/node/866202/psn-pdf
July 24, 2024 - Medication Without Harm - How Digital Healthcare Tools
Can Support Providers and Improve Patient Safety.
June 26, 2024
Agency for Healthcare Research and Quality. July 24, 2024.
https://psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers-
and-improve
Medication errors a…
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psnet.ahrq.gov/node/72710/psn-pdf
February 03, 2021 - A poison information centre can provide important
assessment and guidance regarding medication errors in
nursing homes: a prospective cohort study.
February 3, 2021
Vinther S, Bøgevig S, Eriksen KR, et al. A poison information centre can provide important assessment and
guidance regarding medication errors in nurs…
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psnet.ahrq.gov/node/74110/psn-pdf
November 24, 2021 - New problems and iatrogenic events among older adults
in the first 30 days of post-acute rehabilitation.
November 24, 2021
Simpson M, Kovach CR. New problems and iatrogenic events among older adults in the first 30 days of
post-acute rehabilitation. Res Gerontol Nurs. 2021;14(6):293-304. doi:10.3928/19404921-202109…
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psnet.ahrq.gov/node/74082/psn-pdf
November 17, 2021 - Associations of person-related, environment-related and
communication-related factors on medication errors in
public and private hospitals: a retrospective clinical audit.
November 17, 2021
Manias E, Street M, Lowe G, et al. Associations of person-related, environment-related and
communication-related factors on m…
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psnet.ahrq.gov/node/41186/psn-pdf
January 03, 2017 - The costs of adverse drug events in community hospitals.
January 3, 2017
Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J
Qual Patient Saf. 2012;38(3):120-6.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
Adverse drug events (ADEs) a…
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psnet.ahrq.gov/node/837743/psn-pdf
July 27, 2022 - The New Electronic Health Record’s Unknown Queue
Caused Multiple Events of Patient Harm.
July 27, 2022
Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.
https://psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-
harm
Problems w…
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psnet.ahrq.gov/node/47001/psn-pdf
August 17, 2018 - Realist synthesis of intentional rounding in hospital
wards: exploring the evidence of what works, for whom,
in what circumstances and why.
August 17, 2018
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the
evidence of what works, for whom, in what circumst…
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psnet.ahrq.gov/node/61026/psn-pdf
October 14, 2020 - A blinded, prospective study of error detection during
physician chart rounds in radiation oncology.
October 14, 2020
Talcott WJ, Lincoln H, Kelly JR, et al. A blinded, prospective study of error detection during physician chart
rounds in radiation oncology. Pract Radiat Oncol. 2020;10(5):312-320. doi:10.1016/j.prr…
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psnet.ahrq.gov/node/867011/psn-pdf
October 23, 2024 - Outcomes of Michigan Medicine's integrated patient
safety and communication and resolution program,
2013–2022.
October 23, 2024
Burney RE, Mckeown ES, Zhang Y, et al. Outcomes of Michigan Medicine's integrated patient safety and
communication and resolution program, 2013–2022. J Patient Saf Risk Manag. 2024;29(5):…
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psnet.ahrq.gov/node/47391/psn-pdf
September 12, 2018 - Improving diagnosis by improving education: a policy
brief on education in healthcare professions.
September 12, 2018
Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on
education in healthcare professions. Diagnosis (Berl). 2018;5(3):107-118. doi:10.1515/dx-2018-0033.
…
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psnet.ahrq.gov/node/73441/psn-pdf
June 30, 2021 - Assessment of patient-preferred language to achieve
goal-aligned deprescribing in older adults.
June 30, 2021
Green AR, Aschmann H, Boyd CM, et al. Assessment of patient-preferred language to achieve goal-
aligned deprescribing in older adults. JAMA Netw Open. 2021;4(4):e212633.
doi:10.1001/jamanetworkopen.2021.26…
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psnet.ahrq.gov/node/72717/psn-pdf
February 10, 2021 - Hospital-acquired SARS-Cov-2 infections in patients:
inevitable conditions or medical malpractice?
February 10, 2021
Barranco R, Vallega Bernucci Du Tremoul L, Ventura F. Hospital-acquired SARS-Cov-2 infections in
patients: inevitable conditions or medical malpractice? Int J Environ Res Public Health. 2021;18(2):48…
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psnet.ahrq.gov/node/46446/psn-pdf
September 27, 2017 - Journey toward high reliability: a comprehensive safety
program to improve quality of care and safety culture in a
large, multisite radiation oncology department.
September 27, 2017
Woodhouse KD, Volz E, Maity A, et al. Journey Toward High Reliability: A Comprehensive Safety Program
to Improve Quality of Care and …
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psnet.ahrq.gov/node/46559/psn-pdf
December 22, 2018 - Effect of promoting high-quality staff interactions on fall
prevention in nursing homes: a cluster-randomized trial.
December 22, 2018
Colón-Emeric CS, Corazzini K, McConnell ES, et al. Effect of Promoting High-Quality Staff Interactions on
Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern M…
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psnet.ahrq.gov/node/61067/psn-pdf
January 01, 2021 - A program to provide clinicians with feedback on their
diagnostic performance in a learning health system.
October 28, 2020
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their
diagnostic performance in a learning health system. Jt Comm J Qual Patient Saf. 2021;47(2):120…
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psnet.ahrq.gov/node/864849/psn-pdf
March 20, 2024 - Medication errors in pediatric emergency departments: a
systematic review and recommendations for enhancing
medication safety.
March 20, 2024
Alsabri M, Eapen D, Sabesan V, et al. Medication errors in pediatric emergency departments: a systematic
review and recommendations for enhancing medication safety. Pediatr …
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psnet.ahrq.gov/node/50889/psn-pdf
February 12, 2020 - Unscheduled radiologic examination orders in the
electronic health record: a novel resource for targeting
ambulatory diagnostic errors in radiology.
February 12, 2020
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic
Health Record: A Novel Resource for Targeting Amb…
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psnet.ahrq.gov/node/73879/psn-pdf
September 29, 2021 - Evolving factors in hospital safety: a systematic review
and meta-analysis of hospital adverse events.
September 29, 2021
Sauro KM, Machan M, Whalen-Browne L, et al. Evolving factors in hospital safety: a systematic review and
meta-analysis of hospital adverse events. J Patient Saf. 2021;17(8):e1285-e1295.
doi:10.…
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psnet.ahrq.gov/node/845304/psn-pdf
March 01, 2023 - For children admitted to hospital, what interventions
improve medication safety on ward rounds?
March 1, 2023
King C, Dudley J, Mee A, et al. For children admitted to hospital, what interventions improve medication
safety on ward rounds? A systematic review. Arch Dis Child. 2023;108(7):583-588.
doi:10.1136/archdis…