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psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and
October 12, 2016 - Study
Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.
Citation Text:
Jones A, Johnstone M-J. Inattentional blindness and failures to rescue the deteriorating patient in critical care, em…
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psnet.ahrq.gov/issue/patient-preferences-cases-inter-system-medical-error-discovery-imed
November 02, 2018 - Study
Patient preferences in cases of Inter-system Medical Error Discovery (IMED).
Citation Text:
Antunez AG, Saari A, Miller J, et al. Patient Preferences in Cases of Inter-system Medical Error Discovery (IMED). Ann Surg. 2021;273(3):516-522. doi:10.1097/SLA.0000000000003507.
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psnet.ahrq.gov/issue/nursing-interruptions-trauma-intensive-care-unit-prospective-observational-study
November 09, 2016 - Study
Nursing interruptions in a trauma intensive care unit: a prospective observational study.
Citation Text:
Craker NC, Myers RA, Eid J, et al. Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective Observational Study. J Nurs Adm. 2017;47(4):205-211. doi:10.1097/NNA.0000…
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psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-information-2019
June 22, 2022 - Commentary
ACR guidance document on MR safe practices: updates and critical information 2019.
Citation Text:
ACR guidance document on MR safe practices: updates and critical information 2019. ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 20…
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psnet.ahrq.gov/issue/hassle-dispensary-pilot-study-proactive-risk-monitoring-tool-organisational-learning-based
January 21, 2015 - Study
Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.
Citation Text:
Sujan M-A, Ingram C, McConkey T, et al. Hassle in the dispensary: pilot study of a proactive risk monitoring tool for or…
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www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview
Advancing Excellence in Health Care • www.ahrq.gov
Agency for Healthcare Research and Quality PATIENT
SAFETY
Designing Consumer Reporting
Systems for Patient Safety Events
Background
It’s been nearly a decade since the Institute of
M…
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psnet.ahrq.gov/issue/medication-reconciliation-performed-pharmacy-technicians-time-preoperative-screening
August 18, 2010 - Study
Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.
Citation Text:
van den Bemt PM, van den Broek S, van Nunen AK, et al. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. Ann Pharmaco…
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psnet.ahrq.gov/issue/safer-and-more-appropriate-opioid-prescribing-large-healthcare-systems-comprehensive-approach
June 10, 2020 - Study
Safer and more appropriate opioid prescribing: a large healthcare system's comprehensive approach.
Citation Text:
Losby JL, Hyatt JD, Kanter MH, et al. Safer and more appropriate opioid prescribing: a large healthcare system's comprehensive approach. J Eval Clin Pract. 2017;23(6):1…
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psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pumps-intrathecal-administration-medicines
June 20, 2018 - Press Release/Announcement
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
Citation Text:
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management…
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psnet.ahrq.gov/issue/track-trigger-and-teamwork-communication-deterioration-acute-medical-and-surgical-wards
August 06, 2014 - Study
Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.
Citation Text:
Donohue LA, Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Intensive Crit Care Nurs. 2010;26(1):10-7. doi:…
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psnet.ahrq.gov/issue/hospira-issues-voluntary-nationwide-recall-one-lot-05-bupivacaine-hydrochloride-injection-usp
June 20, 2018 - Press Release/Announcement
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling.
Citation Text:
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivaca…
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psnet.ahrq.gov/issue/assessing-clinical-reasoning-targeting-higher-levels-pyramid
June 15, 2022 - Commentary
Assessing clinical reasoning: targeting the higher levels of the pyramid.
Citation Text:
Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid. J Gen Intern Med. 2019;34(8):1631-1636. doi:10.1007/s11606-019-04953-4.
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psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
July 05, 2017 - Commentary
Supporting perioperative safety during a disaster through clinical crisis education.
Citation Text:
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
Co…
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psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care
March 23, 2011 - Study
The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.
Citation Text:
Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…
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psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
September 28, 2016 - Study
The nature and occurrence of registration errors in the emergency department.
Citation Text:
Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011.
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psnet.ahrq.gov/issue/prioritising-prevention-medication-handling-errors
October 22, 2008 - Study
Prioritising the prevention of medication handling errors.
Citation Text:
Bertsche T, Niemann D, Mayer Y, et al. Prioritising the prevention of medication handling errors. Pharm World Sci. 2008;30(6):907-15. doi:10.1007/s11096-008-9250-3.
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Format:
DOI…
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psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
April 22, 2011 - Study
Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.
Citation Text:
Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…
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psnet.ahrq.gov/issue/electronic-health-record-use-and-quality-ambulatory-care-united-states
May 31, 2023 - Study
Electronic health record use and the quality of ambulatory care in the United States.
Citation Text:
Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400-5.
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F…
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psnet.ahrq.gov/issue/lack-timely-follow-abnormal-imaging-results-and-radiologists-recommendations
April 13, 2017 - Study
Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.
Citation Text:
Al-Mutairi A, Meyer AND, Chang P, et al. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. J Am Coll Radiol. 2015;12(4):385-389. doi:10.1016/…
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psnet.ahrq.gov/issue/resident-uncertainty-clinical-decision-making-and-impact-patient-care-qualitative-study
March 28, 2011 - Study
Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.
Citation Text:
Farnan JM, Johnson JK, Meltzer DO, et al. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care. 2008;…