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psnet.ahrq.gov/node/45536/psn-pdf
October 05, 2016 - Clinician-identified problems and solutions for delayed
diagnosis in primary care: a PRIORITIZE study.
October 5, 2016
Car LT, Papachristou N, Bull A, et al. Clinician-identified problems and solutions for delayed diagnosis in
primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17(1):131. doi:10.1186/s12875-016-0…
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psnet.ahrq.gov/node/46587/psn-pdf
January 23, 2019 - Association between workarounds and medication
administration errors in bar-code-assisted medication
administration in hospitals.
January 23, 2019
van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication
administration errors in bar-code-assisted medication administration…
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psnet.ahrq.gov/node/39404/psn-pdf
March 31, 2010 - Incidence and root cause analysis of wrong-site pain
management procedures: a multicenter study.
March 31, 2010
Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management
procedures: a multicenter study. Anesthesiology. 2010;112(3):711-8. doi:10.1097/ALN.0b013e3181cf892d.
h…
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psnet.ahrq.gov/node/48095/psn-pdf
June 26, 2019 - Exposure to incivility hinders clinical performance in a
simulated operative crisis.
June 26, 2019
Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative
crisis. BMJ Qual Saf. 2019;28(9):750-757. doi:10.1136/bmjqs-2019-009598.
https://psnet.ahrq.gov/issue/ex…
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psnet.ahrq.gov/node/45405/psn-pdf
November 18, 2016 - Relationship between operating room teamwork,
contextual factors, and safety checklist performance.
November 18, 2016
Singer SJ, Molina G, Li Z, et al. Relationship Between Operating Room Teamwork, Contextual Factors,
and Safety Checklist Performance. J Am Coll Surg. 2016;223(4):568-580.e2.
doi:10.1016/j.jamcollsu…
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psnet.ahrq.gov/node/47152/psn-pdf
October 12, 2018 - A quality initiative: a system-wide reduction in serious
medication events through targeted simulation training.
October 12, 2018
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious
Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330…
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - Suicide attempts and completions on medical-surgical
and intensive care units.
September 19, 2016
Mills PD, Watts V, Hemphill RR. Suicide attempts and completions on medical-surgical and intensive care
units. J Hosp Med. 2014;9(3):182-5. doi:10.1002/jhm.2141.
https://psnet.ahrq.gov/issue/suicide-attempts-and-compl…
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psnet.ahrq.gov/node/37543/psn-pdf
March 03, 2011 - Rates of medication errors among depressed and burnt
out residents: prospective cohort study.
March 3, 2011
Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out
residents: prospective cohort study. BMJ. 2008;336(7642):488-91. doi:10.1136/bmj.39469.763218.BE.
https:/…
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psnet.ahrq.gov/node/39266/psn-pdf
March 05, 2010 - The impact of stress on surgical performance: a
systematic review of the literature.
March 5, 2010
Arora S, Sevdalis N, Nestel D, et al. The impact of stress on surgical performance: a systematic review of
the literature. Surgery. 2010;147(3):318-30, 330.e1-6. doi:10.1016/j.surg.2009.10.007.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45207/psn-pdf
August 17, 2016 - Unit-based incident reporting and root cause analysis:
variation at three hospital unit types.
August 17, 2016
Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at
three hospital unit types. BMJ Open. 2016;6(6):e011277. doi:10.1136/bmjopen-2016-011277.
https://psn…
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psnet.ahrq.gov/node/44823/psn-pdf
February 15, 2017 - US poison control center calls for infants 6 months of age
and younger.
February 15, 2017
Kang M, Brooks DE. US Poison Control Center Calls for Infants 6 Months of Age and Younger. Pediatrics.
2016;137(2):e20151865. doi:10.1542/peds.2015-1865.
https://psnet.ahrq.gov/issue/us-poison-control-center-calls-infants-6-m…
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psnet.ahrq.gov/node/46612/psn-pdf
February 22, 2018 - Influencing organisational culture to improve hospital
performance in care of patients with acute myocardial
infarction: a mixed-methods intervention study.
February 22, 2018
Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital
performance in care of patients with acute …
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psnet.ahrq.gov/node/38435/psn-pdf
February 25, 2009 - Prescribing discrepancies likely to cause adverse drug
events after patient transfer.
February 25, 2009
Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after
patient transfer. Qual Saf Health Care. 2009;18(1):32-6. doi:10.1136/qshc.2007.025957.
https://psnet.ah…
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psnet.ahrq.gov/node/45356/psn-pdf
May 09, 2017 - Screening for medication errors using an outlier detection
system.
May 9, 2017
Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system.
J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171.
https://psnet.ahrq.gov/issue/screening-medication-errors-u…
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psnet.ahrq.gov/node/44541/psn-pdf
September 30, 2015 - The effect of universal glove and gown use on adverse
events in intensive care unit patients.
September 30, 2015
Croft LD, Harris AD, Pineles L, et al. The Effect of Universal Glove and Gown Use on Adverse Events in
Intensive Care Unit Patients. Clin Infect Dis. 2015;61(4):545-53. doi:10.1093/cid/civ315.
https://p…
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psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/47296/psn-pdf
September 24, 2018 - The cost of quality: an academic health center's annual
costs for its quality and patient safety infrastructure.
September 24, 2018
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual
costs for its quality and patient safety infrastructure. Jt Comm J Qual Patient …
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psnet.ahrq.gov/node/39069/psn-pdf
February 18, 2011 - Did duty hour reform lead to better outcomes among the
highest risk patients?
February 18, 2011
Volpp KG, Rosen AK, Rosenbaum PR, et al. Did duty hour reform lead to better outcomes among the
highest risk patients? J Gen Intern Med. 2009;24(10):1149-55. doi:10.1007/s11606-009-1011-z.
https://psnet.ahrq.gov/issue/d…
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psnet.ahrq.gov/node/38076/psn-pdf
February 15, 2011 - Consequences of inadequate sign-out for patient care.
February 15, 2011
Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern
Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755.
https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care
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