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psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect-tyre-nichols
July 19, 2023 - Newspaper/Magazine Article
'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?
Citation Text:
'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? Renault M. STAT. February 6, 2023.
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psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
February 01, 2023 - Newspaper/Magazine Article
Assessing medication safety in settings not designated solely for pediatric patients.
Citation Text:
Assessing medication safety in settings not designated solely for pediatric patients. ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5…
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psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error
August 23, 2023 - Commentary
Poor physician-patient communication and medical error.
Citation Text:
Poor physician-patient communication and medical error. Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759.
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psnet.ahrq.gov/issue/some-iv-medications-are-diluted-unnecessarily-patient-care-areas-creating-undue-risk
June 18, 2014 - Newspaper/Magazine Article
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.
Citation Text:
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk. ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19…
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psnet.ahrq.gov/issue/among-elderly-many-mental-illnesses-go-undiagnosed
May 15, 2024 - Commentary
Among the elderly, many mental illnesses go undiagnosed.
Citation Text:
Bor JS. Among the elderly, many mental illnesses go undiagnosed. Health Aff (Millwood). 2015;34(5):727-31. doi:10.1377/hlthaff.2015.0314.
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psnet.ahrq.gov/issue/are-you-well-positioned-resolve-conflicts-safety-order-learning-physicians-homicide-trial-and
May 18, 2022 - Newspaper/Magazine Article
Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.
Citation Text:
Are you well positioned to resolve conflicts with the safety of an order? Learning…
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psnet.ahrq.gov/issue/joint-commission-offers-warnings-advice-adopting-new-health-care-it-systems
September 12, 2016 - Newspaper/Magazine Article
Joint Commission offers warnings, advice on adopting new health care IT systems.
Citation Text:
Mitka M. Joint commission offers warnings, advice on adopting new health care IT systems. JAMA. 2009;301(6):587-9. doi:10.1001/jama.2009.37.
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psnet.ahrq.gov/issue/doctors-unconscious-bias-affects-quality-health-care-services-research-shows
October 21, 2020 - Audiovisual
Doctors' unconscious bias affects quality of health care services, research shows.
Citation Text:
Doctors' unconscious bias affects quality of health care services, research shows. Dembosky A. All Things Considered. National Public Radio. October 15, 2020.
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psnet.ahrq.gov/issue/meeting-challenge-patient-safety-ambulatory-care-setting
February 22, 2023 - Book/Report
Meeting the Challenge of Patient Safety in the Ambulatory Care Setting.
Citation Text:
Meeting the Challenge of Patient Safety in the Ambulatory Care Setting. Turney S, Evans EW, Callaway E, et al. Englewood Cliffs, CO: Medical Group Management Association; 2009.
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psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
January 15, 2020 - Review
There's a science for that: team development interventions in organizations.
Citation Text:
Shuffler ML, DiazGranados D, Salas E. There’s a Science for That. Curr Dir Psychol Sci. 2011;20(6). doi:10.1177/0963721411422054.
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psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
January 26, 2022 - Toolkit
Reducing Adverse Drug Events Related to Opioids Implementation Guide.
Citation Text:
Reducing Adverse Drug Events Related to Opioids Implementation Guide. Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
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psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
February 14, 2024 - Commentary
Why your TeamSTEPPS program may not be working.
Citation Text:
Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs. 2012;9(8). doi:10.1016/j.ecns.2012.03.007.
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psnet.ahrq.gov/issue/cultural-diversity-what-role-does-it-play-patient-safety
June 15, 2011 - Commentary
Cultural diversity: what role does it play in patient safety?
Citation Text:
Ardoin KB, Wilson KB. Cultural diversity: what role does it play in patient safety? Nurs Womens Health. 2010;14(4):322-6. doi:10.1111/j.1751-486X.2010.01563.x.
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psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
May 15, 2024 - Commentary
Antimicrobial stewardship and patient safety.
Citation Text:
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356. doi:10.1016/j.aorn.2016.08.002.
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www.ahrq.gov/patient-safety/reports/engage/interventions/medmanage.html
June 01, 2023 - Medication Management Strategy: Intervention
Patient and Family Engagement in Primary Care
Medication management is a strategy for engaging with patients and caregivers to create a complete and accurate medication list using the brown bag method. A complete and accurate medication list is the foundation for a…
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psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
June 24, 2009 - Commentary
Recognizing the importance of whistleblowers in healthcare.
Citation Text:
O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56. doi:10.1097/01.nurse.0000736912.14380.65.
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psnet.ahrq.gov/issue/challenges-defining-and-measuring-diagnostic-error
February 24, 2021 - Commentary
The challenges in defining and measuring diagnostic error.
Citation Text:
Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis (Berl). 2015;2(2):97-103. doi:10.1515/dx-2014-0069.
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www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
December 01, 2017 - Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient…
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psnet.ahrq.gov/issue/bar-coding-patient-safety
February 12, 2020 - Commentary
Bar coding for patient safety.
Citation Text:
Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353(4):329-31.
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psnet.ahrq.gov/issue/challenges-transparency-reporting-medical-errors
July 19, 2023 - Commentary
The challenges to transparency in reporting medical errors.
Citation Text:
Paterick ZR, Paterick BB, Waterhouse BE, et al. The Challenges to Transparency in Reporting Medical Errors. J Patient Saf. 2009;5(4). doi:10.1097/pts.0b013e3181be2a88.
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