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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
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psnet.ahrq.gov/node/36086/psn-pdf
June 14, 2011 - Sensemaking of patient safety risks and hazards.
June 14, 2011
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv
Res. 2006;41(4 Pt 2):1555-1575.
https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
This commentary discusses the concept of …
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psnet.ahrq.gov/node/41117/psn-pdf
March 04, 2015 - The effectiveness of integrated health information
technologies across the phases of medication
management: a systematic review of randomized
controlled trials.
March 4, 2015
McKibbon A, Lokker C, Handler S, et al. The effectiveness of integrated health information technologies
across the phases of medication man…
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psnet.ahrq.gov/node/47758/psn-pdf
April 17, 2019 - Contribution of adverse events to death of hospitalised
patients.
April 17, 2019
Haukland EC, Mevik K, von Plessen C, et al. Contribution of adverse events to death of hospitalised
patients. BMJ Open Qual. 2019;8(1):e000377. doi:10.1136/bmjoq-2018-000377.
https://psnet.ahrq.gov/issue/contribution-adverse-events-de…
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psnet.ahrq.gov/node/35402/psn-pdf
September 10, 2009 - Can patients be part of the solution? Views on their role
in preventing medical errors.
September 10, 2009
Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing
medical errors. Med Care Res Rev. 2005;62(5):601-16.
https://psnet.ahrq.gov/issue/can-patients-be…
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psnet.ahrq.gov/node/45263/psn-pdf
September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents
decrease patient handoff communication errors.
September 4, 2016
Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease
Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/46278/psn-pdf
July 19, 2017 - The opioid epidemic: what can surgeons do about it?
July 19, 2017
Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
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psnet.ahrq.gov/node/45275/psn-pdf
November 01, 2017 - Electronic tools to support medication reconciliation—a
systematic review.
November 1, 2017
Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J
Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068.
https://psnet.ahrq.gov/issue/electronic-tools-s…
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psnet.ahrq.gov/node/40097/psn-pdf
January 19, 2011 - Use of an electronic information system to identify
adverse events resulting in an emergency department
visit.
January 19, 2011
Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify
adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
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psnet.ahrq.gov/node/46025/psn-pdf
July 11, 2017 - Measuring to improve medication reconciliation in a large
subspecialty outpatient practice.
July 11, 2017
Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large
Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223.
doi:10.1016/j.jcjq.2017.02.005…
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psnet.ahrq.gov/node/865974/psn-pdf
May 29, 2024 - Minimizing bias when using artificial intelligence in
critical care medicine.
May 29, 2024
Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J
Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796.
https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
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psnet.ahrq.gov/node/60227/psn-pdf
April 15, 2020 - The next step in learning from sentinel events in
healthcare.
April 15, 2020
Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare.
BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739.
https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…
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psnet.ahrq.gov/node/867049/psn-pdf
October 30, 2024 - National Review of Maternity Services in England 2022 to
2024.
October 30, 2024
National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality
Commission; September 2024.
https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024
Maternal safety is a gl…
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psnet.ahrq.gov/node/40177/psn-pdf
June 08, 2011 - Learning from disasters to improve patient safety:
applying the generic disaster pathway to health system
errors.
June 8, 2011
Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the
generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8.
doi:1…
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psnet.ahrq.gov/node/853233/psn-pdf
September 06, 2023 - Weight estimation for drug dose calculations in the
prehospital setting - a systematic review.
September 6, 2023
Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a
systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027.
htt…
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psnet.ahrq.gov/node/46298/psn-pdf
October 18, 2017 - CVS taps a design legend to reinvent the prescription
label. Next stop: the pharmacy.
October 18, 2017
Kuang C. Fast Company. October 4, 2017.
https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy
Complicated systems often require more than one change to improve their s…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
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psnet.ahrq.gov/node/46711/psn-pdf
July 01, 2019 - The STOP Measure. Safe and Transparent Opioid
Prescribing to Promote Patient Safety and Reduced Risk
of Opioid Misuse.
July 1, 2019
Washington, DC: America's Health Insurance Plans; 2019.
https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety-
and-reduced-risk
Gu…
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psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - Are second victims getting the help they need?
June 20, 2018
Headley M. Patient Saf Qual Healthc. May/June 2018.
https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are
increasingly building p…
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psnet.ahrq.gov/node/38747/psn-pdf
September 16, 2009 - Examination of how a survey can spur culture changes
using a quality improvement approach: a region-wide
approach to determining a patient safety culture.
September 16, 2009
Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality
improvement approach: a region-wide …