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psnet.ahrq.gov/issue/improving-medication-management-through-redesign-hospital-code-cart-medication-drawer
October 31, 2018 - Study
Improving medication management through the redesign of the hospital code cart medication drawer.
Citation Text:
Rousek JB, Hallbeck MS. Improving Medication Management Through the Redesign of the Hospital Code Cart Medication Drawer. Human Factors: The Journal of the Human Facto…
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psnet.ahrq.gov/issue/adverse-drug-event-related-emergency-department-visits-associated-complex-chronic-conditions
August 20, 2016 - Study
Adverse drug event–related emergency department visits associated with complex chronic conditions.
Citation Text:
Feinstein JA, Feudtner C, Kempe A. Adverse drug event-related emergency department visits associated with complex chronic conditions. Pediatrics. 2014;133(6):e1575-85. …
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psnet.ahrq.gov/issue/patient-safety-assurance-age-defensive-medicine-review
March 09, 2022 - Commentary
Patient safety assurance in the age of defensive medicine: a review.
Citation Text:
Shenoy A, Shenoy GN, Shenoy GG. Patient safety assurance in the age of defensive medicine: a review. Patient Saf Surg. 2022;16(1):10. doi:10.1186/s13037-022-00319-8.
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psnet.ahrq.gov/issue/risk-managers-descriptions-programs-support-second-victims-after-adverse-events
May 11, 2016 - Study
Risk managers' descriptions of programs to support second victims after adverse events.
Citation Text:
White AA, Brock DM, McCotter PI, et al. Risk managers' descriptions of programs to support second victims after adverse events. J Healthc Risk Manag. 2015;34(4):30-40. doi:10.1002…
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psnet.ahrq.gov/issue/nurses-and-nursing-students-second-victims-scoping-review
March 08, 2023 - Review
Nurses and nursing students as second victims: a scoping review.
Citation Text:
Sahay A, McKenna L. Nurses and nursing students as second victims: a scoping review. Nurs Outlook. 2023;71(4):101992. doi:10.1016/j.outlook.2023.101992.
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psnet.ahrq.gov/issue/rate-occult-specimen-provenance-complications-routine-clinical-practice
January 05, 2012 - Study
Rate of occult specimen provenance complications in routine clinical practice.
Citation Text:
Pfeifer JD, Liu J. Rate of occult specimen provenance complications in routine clinical practice. Am J Clin Pathol. 2013;139(1):93-100. doi:10.1309/AJCP50WEZHWIFCIV.
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psnet.ahrq.gov/issue/reporting-patient-safety-incidents-first-experiences-chiropractic-reporting-and-learning
September 11, 2024 - Study
The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning system (CRLS): a pilot study.
Citation Text:
Thiel H, Bolton J. The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning syst…
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/issue/day-discharge-does-not-impact-hospital-readmission-after-major-cardiac-surgery
October 16, 2019 - Study
Day of discharge does not impact hospital readmission after major cardiac surgery.
Citation Text:
Sanaiha Y, Ou R, Ramos G, et al. Day of Discharge Does Not Impact Hospital Readmission After Major Cardiac Surgery. Ann Thorac Surg. 2018;106(6):1767-1773. doi:10.1016/j.athoracsur.201…
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psnet.ahrq.gov/issue/we-need-talk-primary-care-provider-communication-discharge-era-shared-electronic-medical
October 13, 2018 - Study
We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record.
Citation Text:
Sheu L, Fung K, Mourad M, et al. We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record. J …
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psnet.ahrq.gov/issue/information-flow-during-pediatric-trauma-care-transitions-things-falling-through-cracks
February 16, 2022 - Study
Information flow during pediatric trauma care transitions: things falling through the cracks.
Citation Text:
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Information flow during pediatric trauma care transitions: things falling through the cracks. Intern Emerg Med. 2019;14(5):797…
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psnet.ahrq.gov/issue/retrospective-cohort-study-wrong-patient-imaging-order-errors-how-many-reach-patient
February 22, 2023 - Study
Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient?
Citation Text:
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-1…
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psnet.ahrq.gov/issue/standardisation-handoffs-large-academic-paediatric-emergency-department-using-i-pass
October 21, 2020 - Study
The standardisation of handoffs in a large academic paediatric emergency department using I-PASS.
Citation Text:
Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e00125…
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psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
March 20, 2019 - Book/Report
Classic
Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
Citation Text:
Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
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psnet.ahrq.gov/issue/clinical-alerts-decrease-high-risk-medication-use-older-adults
September 02, 2015 - Commentary
Clinical alerts to decrease high-risk medication use in older adults.
Citation Text:
Lord-Adem W, Brandt NJ. Clinical Alerts to Decrease High-Risk Medication Use in Older Adults. J Gerontol Nurs. 2017;43(7):7-12. doi:10.3928/00989134-20170614-04.
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psnet.ahrq.gov/issue/preventing-diagnostic-errors-ambulatory-care-electronic-notification-tool-incomplete
April 22, 2013 - Study
Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests.
Citation Text:
Weingart SN, Yaghi O, Barnhart L, et al. Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests. …
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psnet.ahrq.gov/issue/modified-early-warning-system-improves-patient-safety-and-clinical-outcomes-academic
September 18, 2019 - Study
Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital.
Citation Text:
Mathukia C, Fan WQ, Vadyak K, et al. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Commun…
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psnet.ahrq.gov/issue/accuracy-preliminary-diagnoses-made-paramedics-cross-sectional-comparative-study
September 16, 2020 - Study
The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study.
Citation Text:
Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics – a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med. 2020;…
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psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical-incident
July 27, 2016 - Study
Applying principles from aviation safety investigations to root cause analysis of a critical incident during a simulated emergency.
Citation Text:
Imach S, Eppich W, Zech A, et al. Applying principles from aviation safety investigations to root cause analysis of a critical incident…
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psnet.ahrq.gov/issue/missed-nursing-care-emergency-departments-scoping-review
November 03, 2021 - Review
Missed nursing care in emergency departments: a scoping review.
Citation Text:
Duhalde H, Bjuresäter K, Karlsson I, et al. Missed nursing care in emergency departments: a scoping review. Int Emerg Nurs. 2023;69:101296. doi:10.1016/j.ienj.2023.101296.
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