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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - providers'
cognitive burden and help measure the effectiveness of reconciliation processes (e.g., by calculating
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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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/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/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/74846/psn-pdf
February 16, 2022 - Weight-based Medication Errors in Children.
February 16, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.
https://psnet.ahrq.gov/issue/weight-based-medication-errors-children
Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing,
dispensing…
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psnet.ahrq.gov/node/47894/psn-pdf
April 03, 2019 - What does safety commitment mean to leaders? A multi-
method investigation.
April 3, 2019
Fruhen LS, Griffin MA, Andrei DM. What does safety commitment mean to leaders? A multi-method
investigation. J Safety Res. 2019;68:203-214. doi:10.1016/j.jsr.2018.12.011.
https://psnet.ahrq.gov/issue/what-does-safety-commitme…
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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/864847/psn-pdf
March 20, 2024 - Inter-hospital transfer is an independent risk factor for
hospital-associated infection.
March 20, 2024
Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-
associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:10.1089/sur.2023.077.
https://ps…
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/44188/psn-pdf
June 03, 2015 - The fate of pediatric prescriptions in community
pharmacies.
June 3, 2015
Condren ME, Desselle SP. The fate of pediatric prescriptions in community pharmacies. J Patient Saf.
2015;11(2):79-88. doi:10.1097/PTS.0b013e3182948a7d.
https://psnet.ahrq.gov/issue/fate-pediatric-prescriptions-community-pharmacies
The need…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - A Lot of Pain (Medications)
September 1, 2014
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/lot-pain-medications
Case Objectives
Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids.
Describe the importance of understanding th…
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psnet.ahrq.gov/node/34783/psn-pdf
March 28, 2005 - The organizational and intraorganizational development
of disasters.
March 28, 2005
Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q.
1976;21(3):378. doi:10.2307/2391850.
https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters
This article…
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psnet.ahrq.gov/node/60003/psn-pdf
January 01, 2021 - Systemic causes of in-hospital intravenous medication
errors: a systematic review.
March 4, 2020
Kuitunen S, Niittynen I, Airaksinen M, et al. Systemic causes of in-hospital intravenous medication errors: a
systematic review. J Patient Saf. 2021;17(8):e1660-e1668. doi:10.1097/pts.0000000000000632.
https://psnet.ah…
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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/node/47975/psn-pdf
May 29, 2019 - Surgical Innovation, New Techniques and Technologies:
A Guide to Good Practice.
May 29, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice
Introducing innovations in practice involves taking calculated ri…
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psnet.ahrq.gov/node/35697/psn-pdf
July 12, 2010 - An overview of intravenous-related medication
administration errors as reported to MEDMARX(R), a
national medication error-reporting program.
July 12, 2010
Hicks RW, Becker SC. An overview of intravenous-related medication administration errors as reported to
MEDMARX, a national medication error-reporting program.…
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psnet.ahrq.gov/node/36367/psn-pdf
April 11, 2011 - Emergency medical services system changes reduce
pediatric epinephrine dosing errors in the prehospital
setting.
April 11, 2011
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric
epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…