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psnet.ahrq.gov/issue/nurses-satisfaction-medication-administration-point-care-technology
January 09, 2008 - Study
Nurses' satisfaction with medication administration point-of-care technology.
Citation Text:
Hurley A, Bane A, Fotakis S, et al. Nurses' satisfaction with medication administration point-of-care technology. J Nurs Adm. 2007;37(7-8):343-349.
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psnet.ahrq.gov/issue/can-surveillance-systems-identify-and-avert-adverse-drug-events-prospective-evaluation
February 10, 2015 - Study
Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.
Citation Text:
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial app…
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psnet.ahrq.gov/issue/use-safety-attitudes-questionnaire-measure-patient-safety-improvement
August 18, 2010 - Study
Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.
Citation Text:
Watts B, Percarpio KB, West P, et al. Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement. J Patient Saf. 2010;6(4):206-9.
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psnet.ahrq.gov/issue/using-lean-automation-human-touch-improve-medication-safety-step-closer-perfect-dose
September 16, 2015 - Study
Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."
Citation Text:
Ching JM, Williams BL, Idemoto LM, et al. Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose". Jt Co…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…
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psnet.ahrq.gov/node/49511/psn-pdf
May 01, 2006 - Citrate Mix-Up
May 1, 2006
Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/citrate-mix
The Case
A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a
skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - Liver Biopsy: Proceed With Caution
Citation Text:
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/issue/adverse-drug-events-caused-serious-medication-administration-errors
December 19, 2009 - Study
Adverse drug events caused by serious medication administration errors.
Citation Text:
Kale A, Keohane C, Maviglia SM, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8. doi:10.1136/bmjqs-2012-000946.
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psnet.ahrq.gov/node/36869/psn-pdf
August 31, 2011 - An extra dose of safety.
August 31, 2011
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-
profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
https://psnet.ahrq.gov/issue/extra-dose-safety
This article describes a healt…
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psnet.ahrq.gov/issue/medical-team-training-and-coaching-veterans-health-administration-assessment-and-impact-first
December 21, 2014 - Study
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Citation Text:
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…
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psnet.ahrq.gov/node/42131/psn-pdf
March 20, 2013 - What surgeons leave behind costs some patients dearly.
March 20, 2013
Eisler P.
https://psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly
This newspaper article describes two incidents of retained surgical items and discusses the technological
solutions to prevent them.
https://psnet.ahrq…
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psnet.ahrq.gov/node/39804/psn-pdf
October 13, 2010 - Patient misidentifications caused by errors in standard
barcode technology.
October 13, 2010
Snyder ML, Carter A, Jenkins K, et al. Patient misidentifications caused by errors in standard bar code
technology. Clin Chem. 2010;56(10):1554-60. doi:10.1373/clinchem.2010.150094.
https://psnet.ahrq.gov/issue/patient-mis…
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psnet.ahrq.gov/issue/teamwork-and-communication
February 06, 2019 - Special or Theme Issue
Teamwork and Communication.
Citation Text:
Teamwork and Communication. Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…
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psnet.ahrq.gov/node/39897/psn-pdf
September 26, 2016 - Nurse interruptions pre- and post-implementation of a
point-of-care medication administration system.
September 26, 2016
Stamp KD, Willis DG. Nurse interruptions pre- and postimplementation of a point-of-care medication
administration system. J Nurs Care Qual. 2010;25(3):231-239. doi:10.1097/NCQ.0b013e3181d4a13f.
…
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psnet.ahrq.gov/node/38659/psn-pdf
May 27, 2009 - The Henry Ford Production System: reduction of surgical
pathology in-process misidentification defects by bar
code-specified work process standardization.
May 27, 2009
Zarbo RJ, Tuthill M, D'Angelo R, et al. The Henry Ford Production System: reduction of surgical pathology
in-process misidentification defects by b…
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psnet.ahrq.gov/node/40790/psn-pdf
January 01, 2012 - Nurses' perceptions of simulation-based interprofessional
training program for rapid response and code blue
events.
December 1, 2011
Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. Nurses' perceptions of simulation-based
interprofessional training program for rapid response and code blue events. J Nurs Care Qual.
2…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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