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psnet.ahrq.gov/issue/i-pass-mentored-implementation-handoff-curriculum-implementation-guide-and-resources
November 16, 2022 - Commentary
I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources.
Citation Text:
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. MedEdPORTAL. 2018;14(1):10736. doi:10.15766/me…
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psnet.ahrq.gov/issue/catch-killer-electronic-sepsis-alert-tools-reaching-fever-pitch
November 15, 2023 - Commentary
To catch a killer: electronic sepsis alert tools reaching a fever pitch?
Citation Text:
Ruppel H, Liu V. To catch a killer: electronic sepsis alert tools reaching a fever pitch? BMJ Qual Saf. 2019;28(9):693-696. doi:10.1136/bmjqs-2019-009463.
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psnet.ahrq.gov/issue/using-kotters-change-model-implementing-bedside-handoff-quality-improvement-project
September 23, 2020 - Commentary
Using Kotter's change model for implementing bedside handoff: a quality improvement project.
Citation Text:
Small A, Gist D, Souza D, et al. Using Kotter's Change Model for Implementing Bedside Handoff: A Quality Improvement Project. J Nurs Care Qual. 2016;31(4):304-9. doi:10.…
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psnet.ahrq.gov/issue/measuring-teamwork-health-care-settings-review-survey-instruments
December 14, 2016 - Review
Measuring teamwork in health care settings: a review of survey instruments.
Citation Text:
Valentine MA, Nembhard IM, Edmondson A. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16-e30. doi:10.1097/MLR.0b013e31827feef6.
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psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
September 28, 2022 - Commentary
Emerging Classic
Operational measurement of diagnostic safety: state of the science.
Citation Text:
Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…
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psnet.ahrq.gov/issue/misunderstanding-prescription-drug-warning-labels-among-patients-low-literacy
February 28, 2011 - Study
Misunderstanding of prescription drug warning labels among patients with low literacy.
Citation Text:
Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55.
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psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
September 17, 2010 - Study
Classic
Literacy and misunderstanding prescription drug labels.
Citation Text:
Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887-94.
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psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
July 12, 2023 - Commentary
Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety.
Citation Text:
Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…
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psnet.ahrq.gov/issue/idea4ps-development-research-oriented-learning-healthcare-system
April 24, 2018 - Commentary
IDEA4PS: the development of a research-oriented learning healthcare system.
Citation Text:
Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.…
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psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
November 17, 2021 - Study
The effects of physical environments in medical wards on medication communication processes affecting patient safety.
Citation Text:
Liu W, Manias E, Gerdtz M. The effects of physical environments in medical wards on medication communication processes affecting patient safety. Heal…
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psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach
October 17, 2012 - Review
Preventing medication errors in transitions of care: a patient case approach.
Citation Text:
Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509.
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psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
October 03, 2017 - Study
Preventing wrong site, procedure, and patient events using a common cause analysis.
Citation Text:
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/10628606114120…
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psnet.ahrq.gov/issue/targeting-zero-harm-stretch-goal-risks-breaking-spring
December 01, 2021 - Commentary
Targeting zero harm: a stretch goal that risks breaking the spring.
Citation Text:
Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring. NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354.
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psnet.ahrq.gov/issue/dont-go-hospital-alone-ensuring-safe-highly-reliable-patient-visitation
May 12, 2021 - Commentary
Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.
Citation Text:
Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. Jt Comm J Qual Patient Saf. 2022;48(1):61-64. doi:10.1016/j.jcjq.2021.10.006.
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psnet.ahrq.gov/issue/medical-harm-patient-perceptions-and-follow-actions
September 27, 2017 - Study
Medical harm: patient perceptions and follow-up actions.
Citation Text:
Lyu HG, Cooper M, Mayer-Blackwell B, et al. Medical Harm: Patient Perceptions and Follow-up Actions. J Patient Saf. 2017;13(4):199-201. doi:10.1097/PTS.0000000000000136.
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psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
November 16, 2022 - Study
The Human Factors Analysis Classification System (HFACS) applied to health care.
Citation Text:
Diller T, Helmrich G, Dunning S, et al. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623. …
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psnet.ahrq.gov/issue/reducing-pediatric-emergency-department-prescription-errors
October 26, 2022 - Study
Reducing pediatric emergency department prescription errors.
Citation Text:
Devarajan V, Nadeau NL, Creedon JK, et al. Reducing pediatric emergency department prescription errors. Pediatrics. 2022;149(6):e2020014696. doi:10.1542/peds.2020-014696.
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psnet.ahrq.gov/issue/medication-reconciliation-admission-and-discharge-analysis-prevalence-and-associated-risk
December 02, 2020 - Study
Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors.
Citation Text:
Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, et al. Medication reconciliation at admission and discharge: an analysis of prevalence and associate…
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psnet.ahrq.gov/issue/exploring-concept-medication-discrepancy-within-context-patient-safety-improve-population
November 18, 2020 - Review
Exploring the concept of medication discrepancy within the context of patient safety to improve population health.
Citation Text:
Murphy CR, Corbett CL, Setter SM, et al. Exploring the concept of medication discrepancy within the context of patient safety to improve population h…
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psnet.ahrq.gov/issue/applying-toyota-production-system-principles-psychiatric-hospital-making-transfers-safer-and
January 27, 2016 - Study
Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.
Citation Text:
Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient…