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psnet.ahrq.gov/node/33800/psn-pdf
January 01, 2015 - Computerized Provider Order Entry and Patient Safety
January 1, 2015
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
Annual Perspective 2015
Computerized provider order entry…
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psnet.ahrq.gov/node/35603/psn-pdf
February 06, 2019 - Use of color-coded patient wristbands creates
unnecessary risk.
February 6, 2019
PA PSRS Patient Saf Advis 2005 Dec 2;(Suppl. 2):1-4.
https://psnet.ahrq.gov/issue/use-color-coded-patient-wristbands-creates-unnecessary-risk
This supplemental advisory recommends that a limited, standard set of colors and correspondi…
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psnet.ahrq.gov/node/38583/psn-pdf
May 08, 2018 - Shared MDIs: can cross-contamination be avoided?
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2009;14:1-3.
https://psnet.ahrq.gov/issue/shared-mdis-can-cross-contamination-be-avoided
This article describes the risks of cross-contamination when using shared metered dose inhalers
(MDIs) and…
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psnet.ahrq.gov/node/35600/psn-pdf
June 21, 2010 - Improving nursing unit teamwork.
June 21, 2010
Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550-556.
doi:10.1097/00005110-200512000-00009.
https://psnet.ahrq.gov/issue/improving-nursing-unit-teamwork
The authors share several strategies for improving teamwork among nurses, includ…
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psnet.ahrq.gov/node/38167/psn-pdf
December 17, 2008 - Toward a definition of teamwork in emergency medicine.
December 17, 2008
Fernandez R, Kozlowski SWJ, Shapiro MJ, et al. Toward a definition of teamwork in emergency medicine.
Acad Emerg Med. 2008;15(11):1104-12. doi:10.1111/j.1553-2712.2008.00250.x.
https://psnet.ahrq.gov/issue/toward-definition-teamwork-emergency-…
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psnet.ahrq.gov/node/37611/psn-pdf
February 15, 2011 - SBAR for patients.
February 15, 2011
Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06.
https://psnet.ahrq.gov/issue/sbar-patients
This commentary presents information and background on the standardized communication process known
as SBAR (situation, background, assessment, a…
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…
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psnet.ahrq.gov/issue/i-pass-handoff-program-use-campaign-effect-transformational-change
April 24, 2018 - Study
I-PASS handoff program: use of a campaign to effect transformational change.
Citation Text:
Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088.
Co…
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psnet.ahrq.gov/issue/taxonomy-advancing-systematic-error-analysis-multi-site-electronic-health-record-based
March 24, 2019 - Study
A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical concept extraction.
Citation Text:
Fu S, Wang L, He H, et al. A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical concept ex…
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psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients
June 28, 2017 - Study
The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.
Citation Text:
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis M…
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psnet.ahrq.gov/issue/rates-medical-errors-and-preventable-adverse-events-among-hospitalized-children-following
November 12, 2014 - Study
Classic
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
Citation Text:
Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events…
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psnet.ahrq.gov/issue/effect-pediatric-early-warning-system-all-cause-mortality-hospitalized-pediatric-patients
April 24, 2018 - Study
Classic
Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients.
Citation Text:
Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized …
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psnet.ahrq.gov/issue/power-and-conflict-effect-superiors-interpersonal-behaviour-trainees-ability-challenge
December 13, 2017 - Study
Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.
Citation Text:
Friedman Z, Hayter MA, Everett TC, et al. Power and conflict: the effect of a superior's interpersonal behaviour on…
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psnet.ahrq.gov/issue/medication-dosing-safety-pediatric-patients-recognizing-gaps-safety-threats-and-best
March 01, 2023 - Organizational Policy/Guidelines
Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.
Citation Text:
Cicero MX, Adelgais K, Hoyle JD, et al.…
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psnet.ahrq.gov/issue/effect-two-different-electronic-health-record-user-interfaces-intensive-care-provider-task
March 16, 2022 - Study
The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance.
Citation Text:
Ahmed A, Chandra S, Herasevich V, et al. The effect of two different electronic health record user interfaces on intensi…
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psnet.ahrq.gov/issue/computerized-provider-order-entry-implementation-no-association-increased-mortality-rates
November 16, 2022 - Study
Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.
Citation Text:
Del Beccaro MA, Jeffries HE, Eisenberg MA, et al. Computerized provider order entry implementation: no association with increased mortality ra…
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psnet.ahrq.gov/issue/opioid-prescribing-and-adverse-events-opioid-naive-patients-treated-emergency-physicians
July 18, 2018 - Study
Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study.
Citation Text:
Borgundvaag B, McLeod S, Khuu W, et al. Opioid prescribing and adverse events in opioid-naive patients treated by…
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psnet.ahrq.gov/issue/diagnostic-concordance-among-pathologists-interpreting-breast-biopsy-specimens
July 13, 2016 - Study
Classic
Diagnostic concordance among pathologists interpreting breast biopsy specimens.
Citation Text:
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122-1132. do…
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psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
February 06, 2019 - So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … 2013
The Accreditation Council for Graduate Medical Education resident duty hour new standards
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psnet.ahrq.gov/issue/validation-second-victim-experience-and-support-tool-revised-neonatal-intensive-care-unit
September 24, 2017 - May 19, 2021
Standardization of pediatric noncardiac operating room to intensive care … to enhance compliance of pro re nata medication orders with Joint Commission medication management standards