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psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
May 02, 2018 - Newspaper/Magazine Article
Inside the preventable deaths that happened within a prominent transplant center.
Citation Text:
Inside the preventable deaths that happened within a prominent transplant center. Blau M. ProPublica. June 14, 2023.
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psnet.ahrq.gov/issue/what-practices-will-most-improve-safety-evidence-based-medicine-meets-patient-safety
March 18, 2019 - Commentary
Classic
What practices will most improve safety? Evidence-based medicine meets patient safety.
Citation Text:
Leape L, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4):501-7…
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psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid-19
August 14, 2019 - Organizational Policy/Guidelines
ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection.
Citation Text:
ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. American…
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psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
July 20, 2022 - Commentary
Mindful workarounds in bar code medication administration.
Citation Text:
Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575.
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psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-technology-reduce-medication-errors
August 04, 2021 - Commentary
How informatics nurses use bar code technology to reduce medication errors.
Citation Text:
Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux). 2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37.
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psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-after-adverse-events
May 18, 2022 - Study
When clinicians drop out and start over after adverse events.
Citation Text:
Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008.
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psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned
August 21, 2013 - Commentary
Interdisciplinary team training: five lessons learned.
Citation Text:
Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47-52. doi:10.1097/01.NAJ.0000415127.84605.1f.
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psnet.ahrq.gov/issue/findings-ismp-medication-safety-self-assessment-hospitals
September 26, 2017 - Study
Findings from the ISMP Medication Safety Self-Assessment for hospitals.
Citation Text:
Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Patient Saf. 2003;29(11):586-597.
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psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
January 05, 2012 - Commentary
The road to zero preventable birth injuries.
Citation Text:
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205.
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psnet.ahrq.gov/issue/when-systems-fail
February 10, 2011 - Commentary
When systems fail.
Citation Text:
Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090-2616(01)00025-0.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/adverse-events-root-causes-and-latent-factors
June 21, 2017 - Commentary
Adverse events: root causes and latent factors.
Citation Text:
Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am. 2012;92(1):89-100. doi:10.1016/j.suc.2011.12.003.
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psnet.ahrq.gov/issue/follow-study-medication-errors-reported-vaccine-adverse-event-reporting-system-vaers
May 27, 2011 - Study
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Citation Text:
Varricchio F, Reed J, Group VAERSW. Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS). South Med J. 2006;99(5):486…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Conditions Abscess Legionella, Mycoplasma, Chlamydia (depending on initial antibiotic choice
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - So even if
you had measurement and even if you had choice on the part of the patients and the payers … can piggyback, employers can piggyback, patients can piggyback—on the combination of
measurement and choice
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psnet.ahrq.gov/issue/increasing-patient-safety-neonates-handoff-communication-during-delivery-call
March 19, 2019 - Commentary
Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.
Citation Text:
Vanderbilt AA, Pappada SM, Stein H, et al. Increasing patient safety with neonates via handoff communica…
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - condition of her kidneys.4
As a combined alpha/beta adrenergic blocker, labetalol is seen as an attractive choice … better why the clinicians on both ends of the admission decision felt comfortable with such a risky choice
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psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence-based-evaluation
July 14, 2010 - Commentary
Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.
Citation Text:
Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework.…
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psnet.ahrq.gov/issue/nurse-physician-teamwork-emergency-department-impact-perceptions-job-environment-autonomy-and
November 04, 2012 - Study
Nurse–physician teamwork in the emergency department: impact on perceptions of job environment, autonomy, and control over practice.
Citation Text:
Ajeigbe DO, McNeese-Smith D, Leach LS, et al. Nurse-physician teamwork in the emergency department: impact on perceptions of job env…
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psnet.ahrq.gov/issue/effect-implementation-barcode-technology-and-electronic-medication-administration-record
February 24, 2011 - Study
Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events.
Citation Text:
Truitt E, Thompson R, Blazey-Martin D, et al. Effect of the Implementation of Barcode Technology and an Electronic Medication Administration …
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psnet.ahrq.gov/issue/root-cause-analysis-clinical-error-confronting-disjunction-between-formal-rules-and-situated
June 14, 2011 - Commentary
A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.
Citation Text:
Iedema RAM, Jorm C, Braithwaite J, et al. A root cause analysis of clinical error: confronting the disjunction between formal rules and si…