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psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
June 23, 2021 - Study
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.
Citation Text:
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…
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psnet.ahrq.gov/issue/associations-between-double-checking-and-medication-administration-errors-direct
January 18, 2023 - Study
Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.
Citation Text:
Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration errors: a direct observational st…
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psnet.ahrq.gov/issue/improving-general-practice-computer-systems-patient-safety-qualitative-study-key-stakeholders
October 16, 2012 - Study
Improving general practice computer systems for patient safety: qualitative study of key stakeholders.
Citation Text:
Avery A, Savelyich BSP, Sheikh A, et al. Improving general practice computer systems for patient safety: qualitative study of key stakeholders. Qual Saf Health Ca…
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digital.ahrq.gov/sites/default/files/docs/citation/ddi-non-interruptive-alerts-poster-2013.pdf
January 01, 2013 - 56
151
62
215
0
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Niacins + Statins (Inpatient) Niacins + Statins (Outpatient)
Alerts Overridden Alerts Generated
U.S. System
In the U.S. system, the Niacin + Statin
interaction was triggered and overridden most
often in both inpatient and outpatient systems.
U.K. …
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psnet.ahrq.gov/issue/performance-3-sets-criteria-potentially-inappropriate-prescribing-older-people-identify
December 21, 2022 - Study
Performance of 3 sets of criteria for potentially inappropriate prescribing in older people to identify inadequate drug treatment.
Citation Text:
Wallerstedt SM, Svensson SA, Lönnbro J, et al. Performance of 3 sets of criteria for potentially inappropriate prescribing in older peop…
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psnet.ahrq.gov/issue/avoiding-chemotherapy-prescribing-errors-analysis-and-innovative-strategies
January 02, 2009 - Study
Avoiding chemotherapy prescribing errors: analysis and innovative strategies.
Citation Text:
Reinhardt H, Otte P, Eggleton AG, et al. Avoiding chemotherapy prescribing errors: Analysis and innovative strategies. Cancer. 2019;125(9):1547-1557. doi:10.1002/cncr.31950.
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psnet.ahrq.gov/issue/short-and-long-term-effects-electronic-medication-management-system-paediatric-prescribing
August 28, 2024 - Study
Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.
Citation Text:
Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. NPJ Digit Me…
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psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
May 19, 2021 - Study
Healing our own: a randomized trial to assess benefits of peer support.
Citation Text:
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.…
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psnet.ahrq.gov/issue/patient-activation-related-fall-prevention-multisite-study
February 01, 2023 - Study
Patient activation related to fall prevention: a multisite study
Citation Text:
Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study . Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010.
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Fo…
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psnet.ahrq.gov/issue/shift-shift-nursing-handover-interventions-associated-improved-inpatient-outcomes-falls
July 07, 2021 - Review
Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review.
Citation Text:
Hada A, Coyer F. Shift‐to‐shift nursing handover interventions associated with improved …
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/delpierre-c-et-al-2004
January 01, 2004 - Delpierre C et al. 2004 "A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach?"
Reference
Delpierre C, Cuzin L, Fillaux J, et al. A systematic review of computer-based patient record systems and quality of care: more ra…
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psnet.ahrq.gov/issue/diagnosis-team-sport-partnering-allied-health-professionals-reduce-diagnostic-errors-case
July 28, 2023 - Study
Diagnosis is a team sport—partnering with allied health professionals to reduce diagnostic errors: a case study on the role of a vestibular therapist in diagnosing dizziness.
Citation Text:
Thomas DB, Newman-Toker DE. Diagnosis is a team sport - partnering with allied health profes…
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psnet.ahrq.gov/issue/soft-factors-smooth-transport-role-safety-climate-and-team-processes-reducing-adverse-events
September 27, 2016 - Commentary
Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care.
Citation Text:
Latzke M, Schiffinger M, Zellhofer D, et al. Soft Factors, Smooth Transport? The role of safety climate and…
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psnet.ahrq.gov/issue/understanding-preventable-deaths-geriatric-trauma-population-analysis-3452339-patients-center
February 16, 2022 - Study
Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.
Citation Text:
Ang D, Nieto K, Sutherland M, et al. Understanding preventable deaths in the geriatric trauma population: a…
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psnet.ahrq.gov/issue/developing-and-evaluating-success-family-activated-medical-emergency-team-quality-improvement
December 02, 2014 - Study
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Citation Text:
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report. BMJ …
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psnet.ahrq.gov/issue/improving-emergency-medicine-clinician-awareness-prehospital-administered-medications
October 19, 2022 - Study
Improving emergency medicine clinician awareness of prehospital-administered medications.
Citation Text:
Kamta J, Fregoso B, Lee A, et al. Improving emergency medicine clinician awareness of prehospital-administered medications. Prehosp Emerg Care. 2024;28(3):506-512. doi:10.1080/1…
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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…
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psnet.ahrq.gov/issue/deprescribing-community-dwelling-older-adults-systematic-review-and-meta-analysis
May 05, 2021 - Review
Deprescribing for community-dwelling older adults: a systematic review and meta-analysis.
Citation Text:
Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for community-dwelling older adults: a systematic review and meta-analysis. J Gen Intern Med. 2020;35(11):3323-3332. doi…
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psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-support-deprescribing-interventions-across-veterans
April 24, 2018 - Study
A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.
Citation Text:
Phillips KK, Mecca MC, Baim‐Lance AM, et al. A virtual breakthrough series collaborative to support deprescribing interventions across Vete…
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psnet.ahrq.gov/issue/analysis-incident-reports-related-electronic-medication-management-how-they-change-over-time
March 10, 2021 - Study
An analysis of incident reports related to electronic medication management: how they change over time.
Citation Text:
Kinlay M, Zheng WY, Burke R, et al. An analysis of incident reports related to electronic medication management: how they change over time. J Patient Saf. 2024;20(…