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481. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. | PSNet
     psnet.ahrq.gov/issue/i-pass-illness-diversity-identifies-patients-risk-overnight-clinical-deterioration
     November 16, 2022 - Study I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. Citation Text: Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300…

482. What Have We Learned About Safe Inpatient Handovers? | PSNet
     psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
     March 01, 2011 - phone call to the primary care physician or very little investment made in trying to improve that care transition … handoff usually has three core components: interactive verbal communication, a written communication or "transition … The written communication is sometimes referred to as the transition record, like a transfer note, a

483. Information exchange among physicians caring for the same patient in the community. | PSNet
     psnet.ahrq.gov/issue/information-exchange-among-physicians-caring-same-patient-community
     March 28, 2011 - Study Classic Information exchange among physicians caring for the same patient in the community. Citation Text: van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same patient in the community. CMAJ. 2008;179(10):…

484. Discharge Instructions in the PACU: Who Remembers? | PSNet
     psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
     August 05, 2009 - care resource utilization.( 1-3 ) Unfortunately, communication failures during these moments of transition

485. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital | PSNet
     psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
     May 16, 2022 - medication reconciliation can identify and reduce medication errors, duplications, or omissions at various transition

486. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
     psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
     August 01, 2012 - Best practices to mitigate patient care transition risks are to minimize the number of provider transitions … Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition

487. Handoffs and Handovers | PSNet
     psnet.ahrq.gov/glossary/handoffs-and-handovers
     September 13, 2021 - Handoffs and Handovers September 13, 2021 Anonymous (not verified) See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …

488. Artificial intelligence in anesthetic care: a survey of physician anesthesiologists. | PSNet
     psnet.ahrq.gov/issue/artificial-intelligence-anesthetic-care-survey-physician-anesthesiologists
     March 15, 2016 - Study Artificial intelligence in anesthetic care: a survey of physician anesthesiologists. Citation Text: Estrada Alamo CE, Diatta F, Monsell SE, et al. Artificial intelligence in anesthetic care: a survey of physician anesthesiologists. Anesth Analg. 2024;138(5):938-950. doi:10.1213/ane…

489. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
     psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
     September 28, 2022 - I’d like to transition into discussing patient safety and thinking a little bit more about avoidance … Primary care needs to lead the proactive sharing of information when we transition patients and refer … with us in a timely manner and make sure those patients understand as they come back, that there is a transition

490. Incorporation of quality and safety principles in maintenance of certification: a qualitative analysis of American Board of Medical Specialties member boards. | PSNet
     psnet.ahrq.gov/issue/incorporation-quality-and-safety-principles-maintenance-certification-qualitative-analysis
     July 18, 2018 - Study Incorporation of quality and safety principles in maintenance of certification: a qualitative analysis of American Board of Medical Specialties member boards. Citation Text: Davis JJ, Price DW, Kraft W, et al. Incorporation of Quality and Safety Principles in Maintenance of Certifi…

491. Hospital-based medication reconciliation practices: a systematic review. | PSNet
     psnet.ahrq.gov/issue/hospital-based-medication-reconciliation-practices-systematic-review
     April 05, 2013 - Review Classic Hospital-based medication reconciliation practices: a systematic review. Citation Text: Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-69. do…

492. Center for Innovations in Quality, Effectiveness and Safety. IQuESt! | PSNet
     psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
     April 06, 2022 - Multi-use Website Center for Innovations in Quality, Effectiveness and Safety. IQuESt! Citation Text: Center for Innovations in Quality, Effectiveness and Safety. IQuESt! Houston, TX:  Baylor College of Medicine. Copy Citation Save Save to your library …

493. Health Literacy Tools for Providers of Medication Therapy Management. | PSNet
     psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management
     May 01, 2017 - Toolkit Health Literacy Tools for Providers of Medication Therapy Management. Citation Text: Health Literacy Tools for Providers of Medication Therapy Management. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. Copy Citation Save Save to your…

494. The Wrongful Resuscitation | PSNet
     psnet.ahrq.gov/web-mm/wrongful-resuscitation
     October 12, 2012 - Transitions and Incident Feeding Tube Insertion Among Persons with Advanced Cognitive Impairment: Lost in Transition

495. Preventing Medication Errors: A $21 Billion Opportunity. | PSNet
     psnet.ahrq.gov/issue/preventing-medication-errors-21-billion-opportunity
     December 03, 2008 - Fact Sheet/FAQs Preventing Medication Errors: A $21 Billion Opportunity. Citation Text: Preventing Medication Errors: A $21 Billion Opportunity. Washington, DC: National Priorities Partnership and National Quality Forum; December 2010. Copy Citation Save Save…

496. Hospitals win safety award for simple changes.  | PSNet
     psnet.ahrq.gov/issue/hospitals-win-safety-award-simple-changes
     September 06, 2006 - Newspaper/Magazine Article Hospitals win safety award for simple changes.  Citation Text: Hospitals win safety award for simple changes.  Sipkoff M. Drug Topics. January 22, 2007. Copy Citation Save Save to your library Print Download PDF Sh…

497. State of Healthcare 2008. | PSNet
     psnet.ahrq.gov/issue/state-healthcare-2006
     April 24, 2013 - Book/Report State of Healthcare 2008. Citation Text: State of Healthcare 2008. The Healthcare Commission. London, UK: The Stationary Office; 2008. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

498. Medical Office Survey on Patient Safety Culture. | PSNet
     psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture
     December 24, 2008 - Measurement Tool/Indicator Medical Office Survey on Patient Safety Culture. Citation Text: Medical Office Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. Copy Citation Save Save to your library Print …

499. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. | PSNet
     psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders
     January 10, 2018 - Book/Report Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Citation Text: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Hines S, Luna K, Lofthus J, et al. Rockville, MD: Agency for Healthcare Research and Quality; F…

500. Disruptive clinician behavior: a persistent threat to patient safety. | PSNet
     psnet.ahrq.gov/issue/disruptive-clinician-behavior-persistent-threat-patient-safety
     August 23, 2007 - Commentary Disruptive clinician behavior: a persistent threat to patient safety. Citation Text: Disruptive clinician behavior: a persistent threat to patient safety. Porto G; Lauve R. Patient Safety Quality Healthcare. July / August 2006. Copy Citation Save Sa…