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psnet.ahrq.gov/node/43001/psn-pdf
March 19, 2014 - Variability in the measurement of hospital-wide mortality
rates.
March 19, 2014
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N
Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396.
https://psnet.ahrq.gov/issue/variability-measurement-hospital-wide-m…
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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - Use of computerized physician order entry with clinical
decision support to prevent dose errors in pediatric
medication orders: a systematic review.
March 27, 2024
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical
decision support to prevent dose errors in pedia…
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psnet.ahrq.gov/node/845637/psn-pdf
March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to
improve safety in the cancer treatment prescription and
administration process.
March 8, 2023
Buja A, De Luca G, Ottolitri K, et al. Using Failure Mode, Effect and Criticality Analysis to improve safety in
the cancer treatment prescription and administration p…
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psnet.ahrq.gov/node/842421/psn-pdf
January 11, 2023 - Weight and size descriptors for drug dosing: too many
options and too many errors.
January 11, 2023
Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too
many errors. Am J Health Syst Pharm. 2023;80(2):87-91. doi:10.1093/ajhp/zxac283.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/50736/psn-pdf
December 11, 2019 - Prevalence and nature of medication errors and
preventable adverse drug events in paediatric and
neonatal intensive care settings: a systematic review.
December 11, 2019
Alghamdi AA, Keers RN, Sutherland A, et al. Prevalence and Nature of Medication Errors and Preventable
Adverse Drug Events in Paediatric and Neon…
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psnet.ahrq.gov/issue/ashrm-patient-safety-portal
September 27, 2016 - Multi-use Website
ASHRM Patient Safety Portal.
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March 21, 2012
This Web site provides access to educational resources for risk ma…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/34993/psn-pdf
June 22, 2009 - Five system barriers to achieving ultrasafe health care.
June 22, 2009
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern
Med. 2005;142(9):756-64.
https://psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
This commentary builds on the…
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psnet.ahrq.gov/node/50890/psn-pdf
February 12, 2020 - Impact of pharmacist-led multidisciplinary medication
review on the safety and medication cost of the elderly
people living in a nursing home: a before-after study.
February 12, 2020
Leguelinel-Blache G, Castelli C, Rolain J, et al. Impact of pharmacist-led multidisciplinary medication
review on the safety and med…
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psnet.ahrq.gov/node/35577/psn-pdf
April 06, 2011 - Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the
Manchester Patient Safety Assessment Framework.
April 6, 2011
Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the Manchester…
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/47547/psn-pdf
February 13, 2019 - Prevention of prescription opioid misuse and projected
overdose deaths in the United States.
February 13, 2019
Chen Q, Larochelle MR, Weaver DT, et al. Prevention of Prescription Opioid Misuse and Projected
Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
doi:10.1001/jamanetworkopen.2018.76…
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psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - Preventing pediatric medication errors.
December 23, 2016
Preventing pediatric medication errors. Sentinel event alert. 2008;39:1-4.
https://psnet.ahrq.gov/issue/preventing-pediatric-medication-errors
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk
and to p…
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psnet.ahrq.gov/node/42705/psn-pdf
November 26, 2013 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2013.
November 26, 2013
Oakbrook Terrace, IL: The Joint Commission; October 2013.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2013
This Joint Commission…
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psnet.ahrq.gov/node/35906/psn-pdf
May 27, 2011 - Error reduction in pediatric chemotherapy: computerized
order entry and failure modes and effects analysis.
May 27, 2011
Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and
failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495-8.
https:/…
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - The Financial and Human Cost of Medical Error... and
How Massachusetts Can Lead the Way on Patient Safety.
June 24, 2019
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-
way-patient-safety
The Betsy L…
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psnet.ahrq.gov/node/42652/psn-pdf
October 31, 2014 - Safety in numbers: the development of Leapfrog's
composite patient safety score for US hospitals.
October 31, 2014
Austin M, D'Andrea G, Birkmeyer JD, et al. Safety in numbers: the development of Leapfrog's composite
patient safety score for U.S. hospitals. J Patient Saf. 2014;10(1):64-71.
doi:10.1097/PTS.0b013e31…
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psnet.ahrq.gov/node/41726/psn-pdf
September 26, 2012 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2012.
September 26, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2012
The seventh annual Joint…
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psnet.ahrq.gov/node/42831/psn-pdf
October 31, 2014 - Overdiagnosis in low-dose computed tomography
screening for lung cancer.
October 31, 2014
Patz EF, Pinsky P, Gatsonis C, et al. Overdiagnosis in low-dose computed tomography screening for lung
cancer. JAMA Intern Med. 2014;174(2):269-74. doi:10.1001/jamainternmed.2013.12738.
https://psnet.ahrq.gov/issue/overdiagno…