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psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
July 19, 2023 - Study
Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.
Citation Text:
Balka E, Tolar M, Coates S, et al. Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case st…
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psnet.ahrq.gov/issue/lessons-learned-reducing-negative-impact-adverse-events-patients-health-professionals-and
September 19, 2016 - Study
Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations.
Citation Text:
Mira JJ, Lorenzo S, Carrillo I, et al. Lessons learned for reducing the negative impact of adverse events on patients, health profession…
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psnet.ahrq.gov/issue/challenges-implementing-centers-disease-control-and-prevention-opioid-guideline-consensus
January 25, 2017 - Commentary
Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report.
Citation Text:
Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consens…
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psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-vest-intervention-reduce-medication-errors-during-medication
December 21, 2017 - Study
Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.
Citation Text:
Berdot S, Vilfaillot A, Bézie Y, et al. Effectiveness of a ‘do not interrupt’ vest intervention to…
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psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine-learning-analysis
February 21, 2024 - Study
Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.
Citation Text:
Kaya GK, Ustebay S, Nixon J, et al. Exploring the impact of safety culture on incident reporting: lessons learn…
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psnet.ahrq.gov/issue/opioid-prescribing-practices-2010-through-2015-among-dentists-united-states-what-do-claims
December 20, 2017 - Study
Emerging Classic
Opioid prescribing practices from 2010 through 2015 among dentists in the United States: what do claims data tell us?
Citation Text:
Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the Uni…
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psnet.ahrq.gov/issue/relationship-organizational-culture-stress-satisfaction-and-burnout-physician-reported-error
October 12, 2011 - Study
The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.
Citation Text:
Williams E, Manwell LB, Konrad TR, et al. The relationship of organizational culture, stress, satis…
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psnet.ahrq.gov/issue/staffing-levels-and-nursing-sensitive-patient-outcomes-umbrella-review-and-qualitative-study
May 19, 2021 - Review
Staffing levels and nursing-sensitive patient outcomes: umbrella review and qualitative study.
Citation Text:
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Staffing levels and nursing‐sensitive patient outcomes: umbrella review and qualitative study. Health Serv Res. 2021;56(5…
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psnet.ahrq.gov/issue/flow-information-contributing-medication-incidents-home-care-analysis-considering-incident
May 01, 2024 - Study
Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives.
Citation Text:
Vellonen M, Härkänen M, Välimäki T. Flow of information contributing to medication incidents in home care— an analysis considering inciden…
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psnet.ahrq.gov/issue/capturing-patients-perspectives-medication-safety-development-patient-centered-medication
February 17, 2021 - Study
Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.
Citation Text:
Giles SJ, Lewis PJ, Phipps D, et al. Capturing Patients' Perspectives on Medication Safety: The Development of a Patient-Centered Medication Safe…
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psnet.ahrq.gov/issue/effect-sleep-deprivation-after-night-shift-duty-simulated-crisis-management-residents
August 09, 2023 - Study
Effect of sleep deprivation after a night shift duty on simulated crisis management by residents in anaesthesia. A randomised crossover study.
Citation Text:
Arzalier-Daret S, Buléon C, Bocca M-L, et al. Effect of sleep deprivation after a night shift duty on simulated crisis manag…
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psnet.ahrq.gov/issue/impact-fatigue-and-insufficient-sleep-physician-and-patient-outcomes-systematic-review
October 19, 2022 - Review
Emerging Classic
Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review.
Citation Text:
Gates M, Wingert A, Featherstone R, et al. Impact of fatigue and insufficient sleep on physician and patient outcomes: a syste…
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psnet.ahrq.gov/issue/anesthesia-preinduction-checklist-improve-information-exchange-knowledge-critical-information
July 10, 2013 - Study
An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams.
Citation Text:
Tscholl DW, Weiss M, Kolbe M, et al. An Anesthesia Preinduction Checklist to Improv…
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psnet.ahrq.gov/issue/doctor-was-rude-toilets-are-dirty-utilizing-soft-signals-regulation-patient-safety
October 06, 2021 - Study
The doctor was rude, the toilets are dirty. Utilizing 'soft signals' in the regulation of patient safety.
Citation Text:
Kok J, Wallenburg I, Leistikow I, et al. The doctor was rude, the toilets are dirty. Utilizing ‘soft signals’ in the regulation of patient safety. Safety Sci. 20…
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www.ahrq.gov/news/newsroom/case-studies/202101.html
June 01, 2021 - Duke’s Private Diagnostic Clinic Used TeamSTEPPS to Improve Teamwork and Communications
Search All Impact Case Studies
June 2021
Eighty to 90 percent of medical center leaders at Private Diagnostic Clinic (PDC), a multispecialty physician practice affiliated with Duke Health, reported fewer communications b…
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psnet.ahrq.gov/issue/can-standard-configuration-cardiac-monitor-lead-medical-errors-under-stress-induction
May 19, 2021 - Study
Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?
Citation Text:
Dzisko M, Lewandowska A, Wudarska B. Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction? Sensors (Basel). 2022;22(9):…
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psnet.ahrq.gov/issue/patient-safety-incidents-during-covid-19-health-crisis-france-exploratory-sequential-multi
February 05, 2020 - Study
Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care.
Citation Text:
Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care. Fournier JP…
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psnet.ahrq.gov/issue/parents-perceptions-patient-safety-paediatric-hospital-care-mixed-methods-systematic-review
May 01, 2024 - Review
Parents' perceptions of patient safety in paediatric hospital care-a mixed-methods systematic review.
Citation Text:
Witkowska MI, Janhunen K, Sak‐Dankosky N, et al. Parents' perceptions of patient safety in paediatric hospital care—a mixed‐methods systematic review. J Adv Nurs. 2…
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psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
September 02, 2016 - Congressional Testimony
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
Citation Text:
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. Hearing Before the Subcommittee on Primary Health and Aging, 113th Co…
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psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
January 12, 2022 - Study
Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
Citation Text:
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. B…