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psnet.ahrq.gov/node/39311/psn-pdf
February 17, 2010 - Exploring the role of patients in promoting safety: policy
to practice.
February 17, 2010
Holme A. Exploring the role of patients in promoting safety: policy to practice. Br J Nurs. 2009;18(22):1392-
5.
https://psnet.ahrq.gov/issue/exploring-role-patients-promoting-safety-policy-practice
This commentary examines …
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psnet.ahrq.gov/node/37829/psn-pdf
April 23, 2014 - Hospitals move to reduce risk of night shift.
April 23, 2014
Landro L.
https://psnet.ahrq.gov/issue/hospitals-move-reduce-risk-night-shift
This article reports how hospitals are aiming to boost the safety of care delivered on nights and weekends
by employing "nocturnists" (a hospitalist subspecialty)—physicians wh…
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psnet.ahrq.gov/node/38286/psn-pdf
June 06, 2018 - Actively caring for safety: overcoming bystander apathy.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 20, 2008:13:1-3.
https://psnet.ahrq.gov/issue/actively-caring-safety-overcoming-bystander-apathy
This article provides suggestions to help individuals counteract the tendency for group in…
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psnet.ahrq.gov/node/854832/psn-pdf
October 25, 2023 - Achieving a successful patient safety program with
implementation of a harm reduction strategy.
October 25, 2023
Cohen JB. APSF Newsletter. 2023;38(10):93-95.
https://psnet.ahrq.gov/issue/achieving-successful-patient-safety-program-implementation-harm-reduction-
strategy
Zero harm, while a laudable goal, has been…
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psnet.ahrq.gov/node/866522/psn-pdf
August 14, 2024 - Artificial intelligence in anesthetic care: a survey of
physician anesthesiologists.
August 14, 2024
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.0000000000006752.
https://psnet…
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psnet.ahrq.gov/node/866809/psn-pdf
September 25, 2024 - Stop the line: interventions to prevent retained surgical
items.
September 25, 2024
Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81.
doi:10.1002/aorn.14190.
https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
Retained surgica…
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…
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psnet.ahrq.gov/node/72715/psn-pdf
February 03, 2021 - FDA updates vinca alkaloid labeling for preparation in
intravenous infusion bags only.
February 3, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021.
https://psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
Vinc…
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psnet.ahrq.gov/node/36934/psn-pdf
September 01, 2011 - Recurrent wrong-route drug error – a professional shame.
September 1, 2011
Bell D. Recurrent wrong-route drug error - a professional shame. Anaesthesia. 2007;62(6):541-5.
https://psnet.ahrq.gov/issue/recurrent-wrong-route-drug-error-professional-shame
Referencing three case studies from the same issue, the author d…
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psnet.ahrq.gov/node/34624/psn-pdf
March 17, 2011 - The Leapfrog Group.
March 17, 2011
1775 K St NW, Suite 400, Washington DC 20006. 202-292-6713, info@leapfrog-group.org.
https://psnet.ahrq.gov/issue/leapfrog-group
The Leapfrog Group is an initiative driven by health care purchasers who aim to promote improvements in
the safety, quality, and affordability of healt…
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psnet.ahrq.gov/node/858167/psn-pdf
December 13, 2023 - A proposed approach to allegations of sexual boundary
violation in health care.
December 13, 2023
Cooper WO, Foster JJ, Hickson GB, et al. A proposed approach to allegations of sexual boundary violation
in health care. Jt Comm J Qual Patient Saf. 2023;49(12):671-679. doi:10.1016/j.jcjq.2023.08.006.
https://psnet.a…
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psnet.ahrq.gov/node/866958/psn-pdf
October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
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psnet.ahrq.gov/node/47708/psn-pdf
February 13, 2019 - The role of purple pens in learning to prescribe.
February 13, 2019
Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach.
2019;16(6):598-603. doi:10.1111/tct.12991.
https://psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
Interventions utilizing color as visual c…
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psnet.ahrq.gov/node/47644/psn-pdf
February 13, 2019 - Using computerized virtual cases to explore diagnostic
error in practicing physicians.
February 13, 2019
Trowbridge RL, Reilly JB, Clauser JC, et al. Using computerized virtual cases to explore diagnostic error in
practicing physicians. Diagnosis (Berl). 2018;5(4):229-233. doi:10.1515/dx-2017-0044.
https://psnet.a…
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psnet.ahrq.gov/node/74749/psn-pdf
February 09, 2022 - A safety maturity model for technology-induced errors.
February 9, 2022
Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol
Inform. 2022;289:447-451. doi:10.3233/shti210954.
https://psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
Although health…
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psnet.ahrq.gov/node/50705/psn-pdf
January 01, 2020 - Closing the loop with ambulatory staff on safety reports.
December 4, 2019
Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt
Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009.
https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…
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psnet.ahrq.gov/node/854389/psn-pdf
October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus
Bundle on Sepsis in Obstetric Care.
October 11, 2023
Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on
Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304.
https://…
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psnet.ahrq.gov/node/857450/psn-pdf
January 01, 2024 - Transforming team performance through
reimplementation of the surgical safety checklist.
December 6, 2023
Etheridge JC, Moyal-Smith R, Yong TT, et al. Transforming team performance through reimplementation of
the surgical safety checklist. JAMA Surg. 2024;159(1):78-86. doi:10.1001/jamasurg.2023.5400.
https://psnet…
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psnet.ahrq.gov/node/866244/psn-pdf
July 10, 2024 - Optimizing the use of dose error reduction software on
intravenous infusion pumps.
July 10, 2024
Hughes K, Cole M, Tims D, et al. Optimizing the use of dose error reduction software on intravenous
infusion pumps. Hosp Pediatr. 2024;14(6):448-454. doi:10.1542/hpeds.2023-007385.
https://psnet.ahrq.gov/issue/optimizi…
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…