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  1. psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report
    February 18, 2011 - Commentary Classic 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. Copy Ci…
  2. 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…
  3. 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…
  4. 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…
  5. 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. Copy Citation Format: …
  6. 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…
  7. 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…
  8. 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. Copy Citation Format: Google Scholar PubMe…
  9. 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…
  10. 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
  11. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  12. 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. Copy Citation Format: Google Scholar BibTeX EndNot…
  13. 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. Copy Citation Format: …
  14. 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…
  15. 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. Copy Citation Format: …
  16. 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…
  17. 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…
  18. 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…
  19. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  20. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

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