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psnet.ahrq.gov/node/837697/psn-pdf
July 20, 2022 - Outsourcing health-care services to the private sector
and treatable mortality rates in England, 2013-20: an
observational study of NHS privatisation.
July 20, 2022
Goodair B, Reeves A. Outsourcing health-care services to the private sector and treatable mortality rates in
England, 2013–20: an observational study …
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psnet.ahrq.gov/node/44005/psn-pdf
April 08, 2015 - Case report of a medication error by look-alike packaging:
a classic surrogate marker of an unsafe system.
April 8, 2015
Schnoor J, Rogalski C, Frontini R, et al. Case report of a medication error by look-alike packaging: a
classic surrogate marker of an unsafe system. Patient Saf Surg. 2015;9:12. doi:10.1186/s1303…
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psnet.ahrq.gov/node/38690/psn-pdf
April 07, 2010 - Are verbal orders a threat to patient safety?
April 7, 2010
Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? Qual Saf Health Care.
2009;18(3):165-168. doi:10.1136/qshc.2009.034041.
https://psnet.ahrq.gov/issue/are-verbal-orders-threat-patient-safety
Verbal orders (VOs) are often complex co…
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psnet.ahrq.gov/node/860716/psn-pdf
January 17, 2024 - Nurses' perception of medication administration errors
and factors associated with their reporting in the neonatal
intensive care unit.
January 17, 2024
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Nurses’ perception of medication administration errors
and factors associated with their reporting in the neonatal…
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psnet.ahrq.gov/node/41186/psn-pdf
January 03, 2017 - The costs of adverse drug events in community hospitals.
January 3, 2017
Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J
Qual Patient Saf. 2012;38(3):120-6.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
Adverse drug events (ADEs) a…
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psnet.ahrq.gov/node/865592/psn-pdf
April 17, 2024 - Associations between organizational communication and
patients' experience of prolonged emotional impact
following medical errors.
April 17, 2024
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Associations between organizational communication and
patients' experience of prolonged emotional impact following medica…
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psnet.ahrq.gov/node/836929/psn-pdf
April 13, 2022 - The impact of "missed nursing care" or "care not done"
on adults in health care: a rapid review for the Consensus
Development Project.
April 13, 2022
Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid
review for the Consensus Development Project. Nurs Open. …
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psnet.ahrq.gov/node/867228/psn-pdf
December 04, 2024 - Risk factors for wrong-patient medication orders in the
emergency department.
December 4, 2024
Krummrey G, Sauter TC, Hautz WE, et al. Risk factors for wrong-patient medication orders in the
emergency department. JAMIA Open. 2024;7(4):ooae103. doi:10.1093/jamiaopen/ooae103.
https://psnet.ahrq.gov/issue/risk-factor…
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psnet.ahrq.gov/node/47042/psn-pdf
June 13, 2018 - Addressing dual patient and staff safety through a team-
based standardized patient simulation for agitation
management in the emergency department.
June 13, 2018
Wong AH, Auerbach MA, Ruppel H, et al. Addressing Dual Patient and Staff Safety Through A Team-
Based Standardized Patient Simulation for Agitation Mana…
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psnet.ahrq.gov/node/72851/psn-pdf
March 17, 2021 - Effect of a multifaceted clinical pharmacist intervention
on medication safety after hospitalization in persons
prescribed high-risk medications: a randomized clinical
trial.
March 17, 2021
Gurwitz JH, Kapoor A, Garber L, et al. Effect of a multifaceted clinical pharmacist intervention on
medication safety after …
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psnet.ahrq.gov/node/46835/psn-pdf
February 28, 2018 - Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system.
February 28, 2018
Bledsoe S, Van Buskirk A, Falconer J, et al. Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system. Am J Health Syst Pharm. 2018;75…
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psnet.ahrq.gov/node/854829/psn-pdf
January 01, 2024 - Flow of information contributing to medication incidents
in home care- an analysis considering incident reporters'
perspectives.
October 25, 2023
Vellonen M, Härkänen M, Välimäki T. Flow of information contributing to medication incidents in home
care— an analysis considering incident reporters' perspectives. J Cl…
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psnet.ahrq.gov/node/35328/psn-pdf
May 19, 2015 - Applicability of Healthcare Failure Mode and Effects
Analysis to healthcare epidemiology: evaluation of the
sterilization and use of surgical instruments.
May 19, 2015
Weinstein RA, Linkin DR, Sausman C, et al. Applicability of Healthcare Failure Mode and Effects Analysis
to Healthcare Epidemiology: Evaluation of …
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psnet.ahrq.gov/node/40079/psn-pdf
December 18, 2014 - Adverse events from cough and cold medications after a
market withdrawal of products labeled for infants.
December 18, 2014
Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market
withdrawal of products labeled for infants. Pediatrics. 2010;126(6):1100-7. doi:10.1542/p…
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psnet.ahrq.gov/node/34845/psn-pdf
June 30, 2011 - The JCAHO patient safety event taxonomy: a
standardized terminology and classification schema for
near misses and adverse events.
June 30, 2011
Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety event taxonomy: a standardized
terminology and classification schema for near misses and adverse events. In…
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psnet.ahrq.gov/node/38721/psn-pdf
June 25, 2009 - Effect of bar-code–assisted medication administration on
medication error rates in an adult medical intensive care
unit.
June 25, 2009
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on
medication error rates in an adult medical intensive care unit. Am J Health Syst Ph…
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psnet.ahrq.gov/node/45493/psn-pdf
December 07, 2016 - The rising frequency of IT blackouts indicates the
increasing relevance of IT emergency concepts to ensure
patient safety.
December 7, 2016
Sax U, Lipprandt M, Röhrig R. The Rising Frequency of IT Blackouts Indicates the Increasing Relevance of
IT Emergency Concepts to Ensure Patient Safety. Yearb Med Inform. 2016…
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psnet.ahrq.gov/node/865873/psn-pdf
May 15, 2024 - A review of medication errors and the second victim in
pediatric pharmacy.
May 15, 2024
Bredenkamp K, Raschka MJ, Holmes A. A review of medication errors and the second victim in pediatric
pharmacy. J Pediatr Pharmacol Ther. 2024;29(2):100-106. doi:10.5863/1551-6776-29.2.100.
https://psnet.ahrq.gov/issue/review-me…
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psnet.ahrq.gov/node/73883/psn-pdf
September 29, 2021 - Emergency departments are higher-risk locations for
wrong blood in tube errors.
September 29, 2021
Dunbar NM, Delaney M, Murphy MF, et al. Emergency departments are higher?risk locations for wrong
blood in tube errors. Transfusion (Paris). 2021;61(9):2601-2610. doi:10.1111/trf.16588.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/47184/psn-pdf
August 08, 2018 - Delivering on the promise of CLER: a patient safety
rotation that aligns resident education with hospital
processes.
August 8, 2018
Patel E, Muthusamy V, Young JQ. Delivering on the Promise of CLER: A Patient Safety Rotation That
Aligns Resident Education With Hospital Processes. Acad Med. 2018;93(6):898-903.
doi…