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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
January 01, 2003 - fragile hospitalized patient.4, 5
The principal substantive distinction between the adverse events caused … the burden of potentially
preventable adverse events, deaths, and excess long-term health care costs caused
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hcup-us.ahrq.gov/reports/methods/KIDComp1997Final.pdf
March 16, 2001 - Many of
the differences found may be caused by the absence of payer information from over 10 percent … Diagnosis Groups
218: Liveborn 675,290 33691
128: Asthma 86,698 2731
122: Pneumonia (except caused … 126: Other upper
respiratory infections
218: Liveborn
128: Asthma
122: Pneumonia (except
that caused … Discharges
218: Liveborn 675,290 675,290
128: Asthma 86,698 86,698
122: Pneumonia (except
caused
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effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/alcohol-pharma-final-protocol.pdf
January 01, 2023 - or being sick from drinking) often interfered with taking care
of home or family responsibilities, caused … problems at work, or caused problems
at school. … (4) continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused … of having a persistent or
recurrent physical or psychological problem that is likely to have been caused
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - Severe multisystem disease without a clear diagnosis is more often caused by infection, malignancy, or
-
psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Different recollections of the timing of certain actions
were expressed, which caused some heated interchanges
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psnet.ahrq.gov/node/44380/psn-pdf
October 26, 2018 - From Safety-I to Safety-II: A White Paper.
October 26, 2018
Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper
To enhance patient safety, researchers must consider complexity in health care settings. This white pape…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/36620/psn-pdf
January 14, 2024 - ISMP's List of High-Alert Medications in Acute Care
Settings.
January 14, 2024
Horsham, PA; Institute for Safe Medication Practices: 2024.
https://psnet.ahrq.gov/issue/ismps-list-high-alert-medications-acute-care-settings
This fact sheet lists medications with a high risk of causing significant harm to patients wh…
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psnet.ahrq.gov/node/35244/psn-pdf
December 17, 2008 - Representative case series from public hospital
admissions 1998 II: surgical adverse events.
December 17, 2008
Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II:
surgical adverse events. N Z Med J. 2005;118(1219):U1591.
https://psnet.ahrq.gov/issue/representat…
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psnet.ahrq.gov/node/46881/psn-pdf
March 28, 2018 - Designing for Safety in the ICU.
March 28, 2018
Hamilton DK, ed. Crit Care Nurs Q. 2018;41(1):1-92.
https://psnet.ahrq.gov/issue/designing-safety-icu
Systems and space design are important considerations for safe care delivery. This special issue explores
how the built environment can affect safety in intensive ca…
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psnet.ahrq.gov/node/46073/psn-pdf
May 30, 2018 - The burnout crisis in American medicine.
May 30, 2018
Xu R. The Atlantic. May 11, 2018.
https://psnet.ahrq.gov/issue/burnout-crisis-american-medicine
Clinician burnout is a growing concern in health care. This magazine article illustrates how ineffective
electronic health record systems contribute to the problem a…
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psnet.ahrq.gov/node/46927/psn-pdf
April 04, 2018 - Clinician Well-Being Knowledge Hub.
April 4, 2018
Washington, DC: National Academy of Medicine.
https://psnet.ahrq.gov/issue/clinician-well-being-knowledge-hub
Clinician burnout can detract from individual wellness, patient safety, and organizational health. This
website serves as a companion to a collaborative ef…
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psnet.ahrq.gov/node/40360/psn-pdf
April 22, 2011 - The influence of formulation and medicine delivery
system on medication administration errors in care
homes for older people.
April 22, 2011
Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on
medication administration errors in care homes for older people. BMJ Q…
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psnet.ahrq.gov/node/46224/psn-pdf
July 12, 2017 - Systematic approaches to adverse events in obstetrics,
Part 1 & Part 2.
July 12, 2017
Pettker CM. Systematic approaches to adverse events in obstetrics, Part I: Event identification and
classification. Semin Perinatol. 2017;41(3). doi:10.1053/j.semperi.2017.03.003.
https://psnet.ahrq.gov/issue/systematic-approache…
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psnet.ahrq.gov/node/45612/psn-pdf
November 09, 2016 - Pharmacist work stress and learning from quality related
events.
November 9, 2016
Boyle TA, Bishop A, Morrison B, et al. Pharmacist work stress and learning from quality related events. Res
Social Adm Pharm. 2016;12(5):772-83. doi:10.1016/j.sapharm.2015.10.003.
https://psnet.ahrq.gov/issue/pharmacist-work-stress-a…
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psnet.ahrq.gov/node/857446/psn-pdf
December 06, 2023 - Community Health Systems’ ongoing journey to zero
preventable harm.
December 6, 2023
Simon LT, Van Buren T. Community Health Systems’ ongoing journey to zero preventable harm. NEJM
Catal Innov Care Deliv. 2023;4(12). doi:10.1056/cat.23.0250.
https://psnet.ahrq.gov/issue/community-health-systems-ongoing-journey-zer…
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…
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psnet.ahrq.gov/node/37998/psn-pdf
April 18, 2011 - Awareness with recall during general anaesthesia: a
prospective observational evaluation of 4001 patients.
April 18, 2011
Errando CL, Sigl JC, Robles M, et al. Awareness with recall during general anaesthesia: a prospective
observational evaluation of 4001 patients. Br J Anaesth. 2008;101(2):178-85. doi:10.1093/bja…
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psnet.ahrq.gov/node/43406/psn-pdf
August 06, 2014 - A comparison of the effects of different typographical
methods on the recognizability of printed drug names.
August 6, 2014
Or CKL, Wang H. A comparison of the effects of different typographical methods on the recognizability of
printed drug names. Drug Saf. 2014;37(5):351-9. doi:10.1007/s40264-014-0156-9.
https:/…
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psnet.ahrq.gov/node/866823/psn-pdf
September 25, 2024 - Understanding human factors in patient safety when
prescribing.
September 25, 2024
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical
Journal. September 2024;313(7989).
https://psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
Prescripti…