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psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report
February 18, 2011 - Commentary
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Improving patient safety—five years after the IOM report.
Citation Text:
Altman DE, Clancy CM, Blendon RJ. Improving Patient Safety — Five Years after the IOM Report. New Engl J Med. 2004;351(20):2041-2043. doi:10.1056/nejmp048243.
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psnet.ahrq.gov/issue/prospective-pilot-intervention-study-prevent-medication-errors-drugs-administered-children
December 04, 2015 - Study
Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents.
Citation Text:
Bertsche T, Bertsche A, Krieg E-M, et al. Prospective pilot intervention study to prevent m…
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psnet.ahrq.gov/issue/electronic-detection-delayed-test-result-follow-patients-hypothyroidism
September 27, 2017 - Study
Electronic detection of delayed test result follow-up in patients with hypothyroidism.
Citation Text:
Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-0…
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods
September 09, 2015 - Study
Failure mode and effects analysis: a comparison of two common risk prioritisation methods.
Citation Text:
McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf. 2016;25(5):329-336. doi:10…
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psnet.ahrq.gov/issue/patient-perspectives-patient-provider-communication-after-adverse-events
March 28, 2011 - Study
Patient perspectives of patient–provider communication after adverse events.
Citation Text:
Duclos CW, Eichler M, Taylor L, et al. Patient perspectives of patient-provider communication after adverse events. Int J Qual Health Care. 2005;17(6):479-86.
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psnet.ahrq.gov/issue/improving-diagnosis-health-care
September 12, 2018 - Book/Report
Classic
Improving Diagnosis in Health Care.
Citation Text:
Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…
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psnet.ahrq.gov/issue/effect-organizational-network-patient-safety-safety-event-reporting
October 16, 2013 - Study
The effect of an organizational network for patient safety on safety event reporting.
Citation Text:
Jeffs L, Hayes C, Smith O, et al. The effect of an organizational network for patient safety on safety event reporting. Eval Health Prof. 2014;37(3):366-78. doi:10.1177/016327871349…
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psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
November 26, 2008 - Study
Classic
Operating room briefings and wrong-site surgery.
Citation Text:
Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.
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psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
October 03, 2017 - Study
Preventing wrong site, procedure, and patient events using a common cause analysis.
Citation Text:
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/10628606114120…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - This type of hands-on, guided learning promotes confidence and enhances the patient’s ability to correctly
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. 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/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
September 24, 2014 - Study
Retained surgical items: a problem yet to be solved.
Citation Text:
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
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psnet.ahrq.gov/issue/mhealth-design-promote-medication-safety-children-medical-complexity
July 14, 2010 - Study
An mHealth design to promote medication safety in children with medical complexity.
Citation Text:
Jolliff A, Coller RJ, Kearney H, et al. An mHealth design to promote medication safety in children with medical complexity. Appl Clin Inform. 2024;15(1):45-54. doi:10.1055/a-2214-8000…
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psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
January 17, 2012 - Study
Classic
Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
Citation Text:
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…
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psnet.ahrq.gov/issue/pictograms-units-and-dosing-tools-and-parent-medication-errors-randomized-study
December 14, 2016 - Study
Pictograms, units and dosing tools, and parent medication errors: a randomized study.
Citation Text:
Yin S, Parker RM, Sanders LM, et al. Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics. 2017;140(1):e20163237. doi:10.1542/peds.2016-3…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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