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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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psnet.ahrq.gov/issue/effect-increased-inpatient-attending-physician-supervision-medical-errors-patient-safety-and
December 07, 2011 - July 18, 2018
An assessment of basic patient safety skills in residents entering the
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psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-adverse-event-reporting-and-tracking
July 22, 2020 - Book/Report
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Citation Text:
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. Thompson WC Jr. New York, NY: Off…
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
April 28, 2021 - Commentary
Thinking in three's: changing surgical patient safety practices in the complex modern operating room.
Citation Text:
Gibbs VC. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. World J Gastroenterol. 2012;18(46):6712-9. doi:…
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psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
March 10, 2021 - Newspaper/Magazine Article
Prevent errors during emergency use of hypertonic sodium chloride solutions.
Citation Text:
Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
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psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-care-coordination-veterans
July 27, 2022 - Book/Report
Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.
Citation Text:
Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administra…
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psnet.ahrq.gov/issue/provider-interruptions-and-patient-perceptions-care-observational-study-emergency-department
June 26, 2024 - Study
Provider interruptions and patient perceptions of care: an observational study in the emergency department.
Citation Text:
Schneider A, Wehler M, Weigl M. Provider interruptions and patient perceptions of care: an observational study in the emergency department. BMJ Qual Saf. 2019;…
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psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
May 15, 2024 - Commentary
Positive deviance: a different approach to achieving patient safety.
Citation Text:
Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf. 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115.
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psnet.ahrq.gov/issue/determination-health-care-teamwork-training-competencies-delphi-study
May 15, 2024 - Study
Determination of health-care teamwork training competencies: a Delphi study.
Citation Text:
Clay-Williams R, Braithwaite J. Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Health Care. 2009;21(6):433-40. doi:10.1093/intqhc/mzp042.
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/issue/influencing-leadership-perceptions-patient-safety-through-just-culture-training
September 24, 2010 - Commentary
Influencing leadership perceptions of patient safety through just culture training.
Citation Text:
Vogelsmeier A, Scott-Cawiezell J, Miller B, et al. Influencing leadership perceptions of patient safety through just culture training. J Nurs Care Qual. 2010;25(4):288-94. doi:…
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psnet.ahrq.gov/issue/improving-hospital-performance-culture-change-not-answer
September 27, 2016 - Commentary
Improving hospital performance: culture change is not the answer.
Citation Text:
Leggat SG, Dwyer J. Improving hospital performance: culture change is not the answer. Healthc Q. 2005;8(2):60-6.
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psnet.ahrq.gov/issue/testing-classification-model-emergency-department-errors
March 02, 2010 - Study
Testing a classification model for emergency department errors.
Citation Text:
Henneman EA, Blank FSJ, Gattasso S, et al. Testing a classification model for emergency department errors. J Adv Nurs. 2006;55(1):90-9.
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psnet.ahrq.gov/issue/emergency-department-medication-lists-are-not-accurate
March 02, 2010 - Study
Emergency department medication lists are not accurate.
Citation Text:
Caglar S, Henneman PL, Blank FS, et al. Emergency department medication lists are not accurate. J Emerg Med. 2011;40(6):613-6. doi:10.1016/j.jemermed.2008.02.060.
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psnet.ahrq.gov/issue/smarter-clinical-checklists-how-minimize-checklist-fatigue-and-maximize-clinician-performance
July 10, 2017 - Commentary
Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance.
Citation Text:
Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.00000…
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psnet.ahrq.gov/issue/using-good-catches-promote-just-culture-and-perioperative-patient-safety
July 18, 2018 - Commentary
Using good catches to promote a just culture and perioperative patient safety.
Citation Text:
Monahan JJ. Using Good Catches to Promote a Just Culture and Perioperative Patient Safety. AORN J. 2018;108(5):548-552. doi:10.1002/aorn.12394.
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psnet.ahrq.gov/issue/do-not-put-medication-safety-hold-boarded-patients
September 24, 2010 - Commentary
Do not put medication safety "on hold" with boarded patients.
Citation Text:
Paparella S. Do not put medication safety "on hold" with boarded patients. J Emerg Nurs. 2010;36(4):347-9. doi:10.1016/j.jen.2010.03.008.
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psnet.ahrq.gov/issue/nurses-clinical-reasoning-processes-and-practices-medication-safety
June 15, 2012 - Study
Nurses' clinical reasoning: processes and practices of medication safety.
Citation Text:
Dickson GL, Flynn L. Nurses' clinical reasoning: processes and practices of medication safety. Qual Health Res. 2012;22(1):3-16. doi:10.1177/1049732311420448.
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