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psnet.ahrq.gov/node/40206/psn-pdf
June 15, 2011 - Frequency of pediatric medication administration errors
and contributing factors.
June 15, 2011
Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and
contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e3182031006.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43825/psn-pdf
January 28, 2015 - A systematic review of adult admissions to ICUs related
to adverse drug events.
January 28, 2015
Jolivot P-A, Hindlet P, Pichereau C, et al. A systematic review of adult admissions to ICUs related to
adverse drug events. Crit Care. 2014;18(6):643. doi:10.1186/s13054-014-0643-5.
https://psnet.ahrq.gov/issue/systema…
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psnet.ahrq.gov/node/40730/psn-pdf
August 27, 2012 - Analysis of risk of medical errors using structural-
equation modelling: a 6-month prospective cohort study.
August 27, 2012
Tanaka M, Tanaka K, Takano T, et al. Analysis of risk of medical errors using structural-equation
modelling: a 6-month prospective cohort study. BMJ Qual Saf. 2012;21(9):784-790. doi:10.1136/…
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psnet.ahrq.gov/node/74276/psn-pdf
January 19, 2022 - Guideline for Prevention of Unintentionally Retained
Surgical Items.
January 19, 2022
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6.
doi:10.1002/aorn.13579.
https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
Retained su…
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psnet.ahrq.gov/node/37598/psn-pdf
March 12, 2008 - Patient safety in trauma: maximal impact management
errors at a level I trauma center.
March 12, 2008
Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at
a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-272.
doi:10.1097/TA.0b013e318163359d.…
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psnet.ahrq.gov/node/74188/psn-pdf
December 15, 2021 - Semantically ambiguous language in the teaching
operating room.
December 15, 2021
Liu C, McKenzie A, Sutkin G. Semantically ambiguous language in the teaching operating room. J Surg
Edu. 2021;78(6):1938-1947. doi:10.1016/j.jsurg.2021.03.020.
https://psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-ope…
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psnet.ahrq.gov/node/42049/psn-pdf
February 20, 2013 - Mitigating error vulnerability at the transition of care
through the use of health IT applications.
February 20, 2013
Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the
Use of Health IT Applications. J Med Syst. 2012;36(6). doi:10.1007/s10916-012-9855-x.
https:…
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psnet.ahrq.gov/node/34922/psn-pdf
February 25, 2009 - Potential errors and their prevention in operating room
teamwork as experienced by Finnish, British and
American nurses.
February 25, 2009
Silén-Lipponen M, Tossavainen K, Turunen H, et al. Potential errors and their prevention in operating room
teamwork as experienced by Finnish, British and American nurses. Int …
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psnet.ahrq.gov/node/43961/psn-pdf
August 02, 2015 - Reducing inappropriate polypharmacy: the process of
deprescribing.
August 2, 2015
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing.
JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324.
https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…
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psnet.ahrq.gov/node/43033/psn-pdf
March 12, 2014 - Current challenges and future perspectives for patient
safety in surgery.
March 12, 2014
Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery.
Patient Saf Surg. 2014;8(1):9. doi:10.1186/1754-9493-8-9.
https://psnet.ahrq.gov/issue/current-challenges-and-future-pe…
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psnet.ahrq.gov/node/43218/psn-pdf
July 28, 2014 - Risk management—learning from the mistakes of others.
July 28, 2014
Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7.
doi:10.1111/jep.12165.
https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others
This commentary introduces a structured process for …
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psnet.ahrq.gov/node/46944/psn-pdf
March 21, 2018 - Critical Deficiencies at the Washington DC VA Medical
Center.
March 21, 2018
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No.
17-02644-130.
https://psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
Systemic weaknesses in the Veterans A…
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psnet.ahrq.gov/node/39408/psn-pdf
March 31, 2010 - Patient safety: numerical skills and drug calculation
abilities of nursing students and Registered Nurses.
March 31, 2010
McMullan M, Jones R, Lea S. Patient safety: numerical skills and drug calculation abilities of nursing
students and Registered Nurses. J Adv Nurs. 2010;66(4). doi:10.1111/j.1365-2648.2010.05258.…
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psnet.ahrq.gov/node/60997/psn-pdf
October 07, 2020 - ‘You’re going to release him when he was hurting
himself?’
October 7, 2020
Dahlberg B. Kaiser Health News. September 29, 2020.
https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
This story discusses failures related emergency psychiatric assessment, including premature discharge,
imp…
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psnet.ahrq.gov/node/847731/psn-pdf
April 19, 2023 - Lessons from health care leaders: rethinking and
reinvesting in patient safety.
April 19, 2023
doi:10.1056/CAT.23.0090.
https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety
Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…
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psnet.ahrq.gov/node/38925/psn-pdf
September 16, 2009 - A literature review of the individual and systems factors
that contribute to medication errors in nursing practice.
September 16, 2009
Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute
to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…
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psnet.ahrq.gov/node/41453/psn-pdf
November 26, 2014 - Judging whether a patient is actually improving: more
pitfalls from the science of human perception.
November 26, 2014
Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the
science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…
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psnet.ahrq.gov/node/863003/psn-pdf
February 21, 2024 - Positive Patient Identification.
February 21, 2024
Healthcare Safety Investigation Branch (HSIB), Dorset, UK: Health Services Safety
Investigations Body; February 2024.
https://psnet.ahrq.gov/issue/positive-patient-identification
Patient misidentification can result in medication administration errors, …
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psnet.ahrq.gov/node/43829/psn-pdf
January 14, 2015 - The high cost of low morale in the clinical laboratory: how
workplace environment impacts patient safety.
January 14, 2015
Barker T; Noguez J.
https://psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-
patient-safety
Reporting on the importance of a supportive workpla…
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psnet.ahrq.gov/node/838638/psn-pdf
September 01, 2012 - Directed peer review in surgical pathology.
September 1, 2012
Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337.
doi:10.1097/pap.0b013e31826661b7.
https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
Diagnostic error in pathology can result in delaye…