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psnet.ahrq.gov/issue/increased-patient-safety-related-incidents-following-transition-daylight-savings-time
May 19, 2021 - Study
Increased patient safety-related incidents following the transition into Daylight Savings Time.
Citation Text:
Kolla BP, Coombes BJ, Morgenthaler TI, et al. Increased patient safety-related incidents following the transition into Daylight Savings Time. J Gen Intern Med. 2020;36(1):…
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psnet.ahrq.gov/issue/clinical-pharmacists-and-inpatient-medical-care-systematic-review
September 09, 2013 - Review
Classic
Clinical pharmacists and inpatient medical care: a systematic review.
Citation Text:
Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955-64.
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psnet.ahrq.gov/issue/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 29, 2021 - Study
Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.
Citation Text:
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2021;8(3):347-352. doi…
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psnet.ahrq.gov/issue/monitoring-preventable-adverse-events-and-near-misses-number-and-type-identified-differ
June 08, 2022 - Study
Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.
Citation Text:
Isaksson S, Schwarz A, Rusner M, et al. Monitoring preventable adverse events and near misses: number and type identified differ depending on method use…
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psnet.ahrq.gov/issue/weight-and-size-descriptors-drug-dosing-too-many-options-and-too-many-errors
April 06, 2022 - Commentary
Weight and size descriptors for drug dosing: too many options and too many errors.
Citation Text:
Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too many errors. Am J Health Syst Pharm. 2023;80(2):87-91. doi:10.1093/ajhp/zx…
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psnet.ahrq.gov/issue/patient-safety-reporting-qualitative-study-thoughts-and-perceptions-experts-15-years-after
June 16, 2021 - Study
Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'
Citation Text:
Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after…
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psnet.ahrq.gov/issue/are-we-heeding-warning-signs-examining-providers-overrides-computerized-drug-drug-interaction
September 01, 2016 - Study
Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care.
Citation Text:
Slight SP, Seger DL, Nanji KC, et al. Are we heeding the warning signs? Examining providers' overrides of computerized drug-drug interaction…
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psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons-patient-care
April 13, 2022 - Study
Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care.
Citation Text:
de Vos MS, Hamming JF, Marang-van de Mheen PJ. Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care. J Patient …
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psnet.ahrq.gov/issue/supplemental-perioperative-oxygen-and-risk-surgical-wound-infection-randomized-controlled
March 09, 2022 - Study
Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial.
Citation Text:
Belda J, Aguilera L, de la Asunción JG, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA…
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psnet.ahrq.gov/issue/association-overlapping-surgery-perioperative-outcomes
June 08, 2022 - Study
Emerging Classic
Association of overlapping surgery with perioperative outcomes.
Citation Text:
Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA. 2019;321(8):762-772. doi:10.1001/jama.2019.0711.
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psnet.ahrq.gov/issue/computerized-prescribing-alerts-and-group-academic-detailing-reduce-use-potentially
July 10, 2008 - Study
Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.
Citation Text:
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to reduce the use of poten…
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psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-conferences
August 04, 2015 - Study
Classic
Discussion of medical errors in morbidity and mortality conferences.
Citation Text:
Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290(21):2838-2842.
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psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical-error
June 14, 2011 - Study
Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error.
Citation Text:
Iedema RAM, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Soc Sci Med. 2006;62(7):16…
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psnet.ahrq.gov/issue/taking-heat-or-taking-temperature-qualitative-study-large-scale-exercise-seeking-measure
November 02, 2016 - Study
Classic
Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.
Citation Text:
Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualit…
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psnet.ahrq.gov/issue/learning-high-risk-industries-may-not-be-straightforward-qualitative-study-hierarchy-risk
September 11, 2019 - Study
Classic
Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.
Citation Text:
Liberati EG, Peerally MF, Dixon-Woods M. Learning from high risk industries may not be strai…
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psnet.ahrq.gov/issue/patient-awake-and-we-need-stay-calm-reconsidering-indirect-communication-face-medical-error
October 11, 2023 - Study
"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses.
Citation Text:
Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering indirect communication…
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psnet.ahrq.gov/issue/improving-communication-primary-care-physicians-time-hospital-discharge
November 16, 2022 - Study
Improving communication with primary care physicians at the time of hospital discharge.
Citation Text:
Destino LA, Dixit A, Pantaleoni JL, et al. Improving Communication with Primary Care Physicians at the Time of Hospital Discharge. Jt Comm J Qual Patient Saf. 2017;43(2):80-88. do…
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psnet.ahrq.gov/issue/combining-systems-and-teamwork-approaches-enhance-effectiveness-safety-improvement
January 20, 2015 - Study
Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program.
Citation Text:
McCulloch P, Morgan L, New S, et al. Combining Systems and Teamwork Approaches to Enhance the …
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psnet.ahrq.gov/issue/effects-multifaceted-medication-reconciliation-quality-improvement-intervention-patient
April 12, 2023 - Study
Emerging Classic
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
Citation Text:
Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconcil…
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psnet.ahrq.gov/issue/improving-resident-and-fellow-engagement-patient-safety-through-graduate-medical-education
June 02, 2021 - Study
Improving resident and fellow engagement in patient safety through a graduate medical education incentive program.
Citation Text:
Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program. J …