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psnet.ahrq.gov/node/38625/psn-pdf
November 19, 2009 - The design of the SAFE or SORRY? study: a cluster
randomised trial on the development and testing of an
evidence based inpatient safety program for the
prevention of adverse events.
November 19, 2009
van Gaal BGI, Schoonhoven L, Hulscher M, et al. The design of the SAFE or SORRY? study: a cluster
randomised trial…
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psnet.ahrq.gov/node/46803/psn-pdf
April 12, 2019 - Association between electronic medical record
implementation of default opioid prescription quantities
and prescribing behavior in two emergency departments.
April 12, 2019
Delgado K, Shofer FS, Patel MS, et al. Association between Electronic Medical Record Implementation of
Default Opioid Prescription Quantities …
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psnet.ahrq.gov/node/45922/psn-pdf
April 19, 2017 - Two sides to every story: the Dual Perspectives Method
for examining interruptions in healthcare.
April 19, 2017
McCurdie T, Sanderson P, Aitken LM, et al. Two sides to every story: The Dual Perspectives Method for
examining interruptions in healthcare. Appl Ergon. 2017;58:102-109. doi:10.1016/j.apergo.2016.05.012.…
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psnet.ahrq.gov/node/43787/psn-pdf
June 22, 2016 - Measuring variation in use of the WHO surgical safety
checklist in the operating room: a multicenter prospective
cross-sectional study.
June 22, 2016
Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the
operating room: a multicenter prospective cross-sectional stud…
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psnet.ahrq.gov/node/36303/psn-pdf
October 25, 2010 - Medication dispensing errors and potential adverse drug
events before and after implementing bar code
technology in the pharmacy.
October 25, 2010
Poon EG, Cina J, Churchill WW, et al. Medication dispensing errors and potential adverse drug events
before and after implementing bar code technology in the pharmacy. …
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psnet.ahrq.gov/node/50906/psn-pdf
February 19, 2020 - Implementation of a discharge education program to
improve transitions of care for patients at high risk of
medication errors.
February 19, 2020
Crannage AJ, Hennessey EK, Challen LM, et al. . Implementation of a discharge education program to
improve transitions of care for patients at high risk of medication err…
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psnet.ahrq.gov/node/72857/psn-pdf
March 17, 2021 - Results and lessons from a hospital-wide initiative
incentivised by delivery system reform to improve
infection prevention and sepsis care.
March 17, 2021
Sreeramoju P, Voy-Hatter K, White C, et al. Results and lessons from a hospital-wide initiative incentivised
by delivery system reform to improve infection prev…
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psnet.ahrq.gov/node/73880/psn-pdf
January 01, 2022 - Decreased incidence of cesarean surgical site infection
rate with hospital-wide perioperative bundle.
September 29, 2021
Sood N, Lee RE, To JK, et al. Decreased incidence of cesarean surgical site infection rate with hospital?
wide perioperative bundle. Birth. 2022;49(1):141-146. doi:10.1111/birt.12586.
https://ps…
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psnet.ahrq.gov/node/73399/psn-pdf
June 16, 2021 - Examining causes and prevention strategies of adverse
events in deceased hospital patients: a retrospective
patient record review study in the Netherlands.
June 16, 2021
Smits M, Langelaan M, de Groot J, et al. Examining causes and prevention strategies of adverse events in
deceased hospital patients: a retrospect…
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psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - Preventing pediatric medication errors.
December 23, 2016
Preventing pediatric medication errors. Sentinel event alert. 2008;39:1-4.
https://psnet.ahrq.gov/issue/preventing-pediatric-medication-errors
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk
and to p…
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psnet.ahrq.gov/node/44697/psn-pdf
June 21, 2016 - Saving Lives and Saving Money: Hospital-Acquired
Conditions Update.
June 21, 2016
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-
0009-EF.
https://psnet.ahrq.gov/issue/saving-lives-and-saving-money-hospital-acquired-conditions-update
The Partnership for Patients …
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digital.ahrq.gov/organization/state-university-new-york-buffalo
January 01, 2023 - State University of New York at Buffalo
Implementing Personalized Cross-Sector Transitional Care Management to Promote Care Continuity, Reduce Low-Value Utilization, and Reduce the Burden of Treatment for High-Need, High-Cost Patients
Description
This research will integrate c…
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effectivehealthcare.ahrq.gov/sites/default/files/pregnancy_hi_impact.pdf
January 01, 2012 - reported conditions), poor birth outcomes, and early
childhood morbidities, with the specific aim of reducing … the potential to significantly improve patient
health outcomes, pointing to its potential impact on reducing … unable to provide breast milk for their infant will be able to
receive the health benefits, therefore reducing … surgical intervention to repair myelomeningocele, citing in utero surgical repair’s potential for
reducing
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…
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www.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - Identify Defects Through Sensemaking, Facilitator Notes
CUSP Toolkit
The Identify Defects Through Sensemaking module of the CUSP Toolkit will help you identify recurring negative events in your system and apply CUSP and Sensemaking tools to help reduce the risk of future harm to your patients.
Contents …
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/nMb54adBfgajp8dG87kPcw
April 17, 2018 - 53,56-59
RCTs (n = 7297) with a primary or secondary aim of examining
the effectiveness of exercise on reducing … recruitment from emergency
settings in the multifactorial intervention studies) were more effec-
tive in reducing … Reducing falls among older
people in general practice: the ProAct65+ exercise
intervention trial.
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psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors. … Nearing zero..reducing grade C medication errors.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0543_05-24-2013.pdf
January 01, 2013 - Summary: alternative strategies, including educational strategies and antibiotic management, for
reducing … Individuals with acute cough illness Intervention(s): Educational and
antimicrobial strategies for reducing … present with ACI, what is the comparative effectiveness of various
from Nominator: interventions for reducing
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cds.ahrq.gov/sites/default/files/cds/artifact/136331/Benzodiazepine%20Patient%20Handout.pdf
January 01, 2018 - Microsoft PowerPoint - Updated Handouts - Read-Only
REDUCING MEDICATIONS SAFELY
TO MEET LIFE’S CHANGES … taking:_____________________
Your dose: _____________________________________________
WHY CONSIDER REDUCING … Adapted from “Reducing Medications Safely to Meet Life’s Changes, Focus on Benzodiazepine Receptor Agonists