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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management-learning-tool
June 30, 2013 - Special or Theme Issue
Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool.
Citation Text:
Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool. Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - Harm rates were calculated by clinical data abstraction from approximately 30,000 charts reviewed each … And, harm by harm, we've calculated what the impact of that would be if that nationally representative
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - opioid than the
chronic medication, guidelines advise starting with a dose 25%–50% lower than the calculated … If changing to a different opioid, use a dose 25%–50% lower than the calculated
equianalgesic dose.
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - different opioid than the chronic medication, guidelines advise starting with a dose 25%–50% lower than the calculated … If changing to a different opioid, use a dose 25%–50% lower than the calculated equianalgesic dose.
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
January 06, 2017 - Study
Decreasing errors in pediatric continuous intravenous infusions.
Citation Text:
Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med. 2006;7(3):225-30.
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psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-review
September 09, 2015 - Review
What causes prescribing errors in children? Scoping review.
Citation Text:
Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680.
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DOI Google …
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - Harm rates were calculated by clinical data abstraction from approximately 30,000 charts reviewed each … And, harm by harm, we've calculated what the impact of that would be if that nationally
representative
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psnet.ahrq.gov/issue/impact-electronic-medical-records-data-sources-adverse-drug-event-quality-measure
July 31, 2013 - Study
The impact of electronic medical records data sources on an adverse drug event quality measure.
Citation Text:
Kahn MG, Ranade D. The impact of electronic medical records data sources on an adverse drug event quality measure. J Am Med Inform Assoc. 2010;17(2):185-91. doi:10.1136/…
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psnet.ahrq.gov/issue/standardized-formulary-reduce-pediatric-medication-dosing-errors-mixed-methods-study
August 25, 2021 - Study
A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study.
Citation Text:
Bosson N, Kaji AH, Gausche-Hill M. A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study. Prehosp Emerg Care. 2022;26(4):492-502. doi:…
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psnet.ahrq.gov/issue/adaption-trigger-tool-identify-harmful-incidents-no-harm-incidents-and-near-misses
May 25, 2022 - Study
Adaption of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care of children.
Citation Text:
Packendorff N, Magnusson C, Axelsson C, et al. Adaption of a trigger tool to identify harmful incidents, no harm incidents, and nea…
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psnet.ahrq.gov/issue/clinical-data-sharing-improves-quality-measurement-and-patient-safety
April 21, 2021 - Study
Clinical data sharing improves quality measurement and patient safety.
Citation Text:
D’Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient safety. J Am Med Inform Assoc. 2021;28(7):1534-1542. doi:10.1093/jamia/ocab039.
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psnet.ahrq.gov/issue/paramedics-and-effects-shift-work-sleep-literature-review
July 24, 2017 - Review
Paramedics and the effects of shift work on sleep: a literature review.
Citation Text:
Sofianopoulos S, Williams B, Archer F. Paramedics and the effects of shift work on sleep: a literature review. Emerg Med J. 2012;29(2):152-5. doi:10.1136/emj.2010.094342.
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F…
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psnet.ahrq.gov/node/35772/psn-pdf
March 15, 2006 - Use of dimensional analysis to reduce medication errors.
March 15, 2006
Greenfield S; Whelan B; Cohn E.
https://psnet.ahrq.gov/issue/use-dimensional-analysis-reduce-medication-errors
The investigators tested second-year nursing students on medication dosage calculation and found that
those students who were taught…
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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psnet.ahrq.gov/node/36846/psn-pdf
March 03, 2011 - Information technology cannot guarantee patient safety.
March 3, 2011
de Wildt SN, Verzijden R, van den Anker JN, et al. Information technology cannot guarantee patient safety.
BMJ. 2007;334(7598):851-2.
https://psnet.ahrq.gov/issue/information-technology-cannot-guarantee-patient-safety
The authors provide a case …
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psnet.ahrq.gov/node/35954/psn-pdf
August 02, 2010 - Decreasing errors in pediatric continuous intravenous
infusions.
August 2, 2010
Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions.
Pediatr Crit Care Med. 2006;7(3):225-30.
https://psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
Th…
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psnet.ahrq.gov/node/48135/psn-pdf
August 28, 2019 - What causes prescribing errors in children? Scoping
review.
August 28, 2019
Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ
Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680.
https://psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-rev…
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psnet.ahrq.gov/issue/computerized-order-entry-limited-decision-support-prevent-prescription-errors-picu
January 31, 2018 - Study
Computerized order entry with limited decision support to prevent prescription errors in a PICU.
Citation Text:
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-94…