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psnet.ahrq.gov/primer/checklists
September 15, 2024 - Checklists
Citation Text:
Checklists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 15, 2024 - Breadcrumb
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Created By: AHRQ
Date Created: January 24, 20…
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/46060/psn-pdf
October 31, 2017 - Do hospitals support second victims? Collective insights
from patient safety leaders in Maryland.
October 31, 2017
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient
Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008.
h…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/node/47248/psn-pdf
September 26, 2018 - Frequency and nature of potentially harmful preventable
problems in primary care from the patient's perspective
with clinician review: a population-level survey in Great
Britain.
September 26, 2018
Stocks SJ, Donnelly A, Esmail A, et al. Frequency and nature of potentially harmful preventable problems
in primary …
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psnet.ahrq.gov/node/46000/psn-pdf
April 26, 2017 - Diagnostic error in the emergency department: follow up
of patients with minor trauma in the outpatient clinic.
April 26, 2017
Moonen P-J, Mercelina L, Boer W, et al. Diagnostic error in the Emergency Department: follow up of
patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med. 2017…
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psnet.ahrq.gov/node/35571/psn-pdf
April 06, 2011 - Overestimation of clinical diagnostic performance caused
by low necropsy rates.
April 6, 2011
Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by
low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13.
https://psnet.ahrq.gov/issue/overestimation-clinical-dia…
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psnet.ahrq.gov/node/39987/psn-pdf
September 20, 2011 - Fall prevention in acute care hospitals: a randomized trial.
September 20, 2011
Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA.
2010;304(17):1912-1918. doi:10.1001/jama.2010.1567.
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-t…
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psnet.ahrq.gov/node/44043/psn-pdf
September 20, 2017 - Incident learning in pursuit of high reliability:
implementing a comprehensive, low-threshold reporting
program in a large, multisite radiation oncology
department.
September 20, 2017
Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementing a
comprehensive, low-thre…
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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/45760/psn-pdf
February 08, 2017 - Safe practices for copy and paste in the EHR. Systematic
review, recommendations, and novel model for health IT
collaboration.
February 8, 2017
Tsou AY, Lehmann CU, Michel J, et al. Safe Practices for Copy and Paste in the EHR. Systematic Review,
Recommendations, and Novel Model for Health IT Collaboration. Appl C…
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psnet.ahrq.gov/node/35877/psn-pdf
July 23, 2010 - National Quality Forum 30 safe practices: priority and
progress in Iowa hospitals.
July 23, 2010
Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in
Iowa hospitals. Am J Med Qual. 2006;21(2):101-8.
https://psnet.ahrq.gov/issue/national-quality-forum-30-safe-practi…
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psnet.ahrq.gov/node/42379/psn-pdf
August 08, 2013 - Prevalence and nature of adverse medical device events
in hospitalized children.
August 8, 2013
Brady PW, Varadarajan K, Peterson LE, et al. Prevalence and nature of adverse medical device events in
hospitalized children. J Hosp Med. 2013;8(7):390-3. doi:10.1002/jhm.2058.
https://psnet.ahrq.gov/issue/prevalence-an…
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psnet.ahrq.gov/node/43678/psn-pdf
April 22, 2015 - 'Connecting the dots': leveraging visual analytics to make
sense of patient safety event reports.
April 22, 2015
Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety
event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:10.1136/amiajnl-2014-002963.
https://ps…
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psnet.ahrq.gov/node/35802/psn-pdf
January 02, 2017 - Reconciliation failures lead to medication errors.
January 2, 2017
Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9.
https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
Medication reconciliation represents an active effort of hospita…
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psnet.ahrq.gov/node/34872/psn-pdf
February 09, 2011 - Hospital nurse staffing and patient mortality, nurse
burnout, and job dissatisfaction.
February 9, 2011
Aiken LH, Clarke S, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction. JAMA. 2002;288(16):1987-93.
https://psnet.ahrq.gov/issue/hospital-nurse-staffing-and-p…
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psnet.ahrq.gov/node/34656/psn-pdf
May 27, 2011 - A look into the nature and causes of human errors in the
intensive care unit.
May 27, 2011
Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care
unit. Crit Care Med. 1995;23(2):294-300.
https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-…
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…