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psnet.ahrq.gov/issue/medication-errors-overview-clinicians
September 20, 2011 - Review
Medication errors: an overview for clinicians.
Citation Text:
Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116-25. doi:10.1016/j.mayocp.2014.05.007.
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psnet.ahrq.gov/issue/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label
March 12, 2010 - Government Resource
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Citation Text:
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and …
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psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
April 06, 2016 - Book/Report
National Reporting and Learning System Research and Development.
Citation Text:
National Reporting and Learning System Research and Development. Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
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psnet.ahrq.gov/issue/oversight-hearing-recent-patient-safety-issues
November 06, 2019 - Congressional Testimony
Oversight Hearing on Recent Patient Safety Issues.
Citation Text:
Oversight Hearing on Recent Patient Safety Issues. U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of Representatives, Subcommittee on Oversight and…
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psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-beneficiaries
December 04, 2016 - Study
Hospital prescribing of opioids to Medicare beneficiaries.
Citation Text:
Jena AB, Goldman D, Karaca-Mandic P. Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Intern Med. 2016;176(7):990-7. doi:10.1001/jamainternmed.2016.2737.
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psnet.ahrq.gov/issue/improved-obstetric-safety-through-programmatic-collaboration
September 23, 2020 - Commentary
Improved obstetric safety through programmatic collaboration.
Citation Text:
Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration. J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131.
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psnet.ahrq.gov/issue/why-do-hundreds-us-women-die-annually-childbirth
June 14, 2019 - Commentary
Why do hundreds of US women die annually in childbirth?
Citation Text:
Slomski A. Why Do Hundreds of US Women Die Annually in Childbirth? JAMA. 2019;321(13):1239-1241. doi:10.1001/jama.2019.0714.
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psnet.ahrq.gov/issue/challenges-faced-providing-safe-care-rural-perinatal-settings
June 14, 2017 - Study
Challenges faced in providing safe care in rural perinatal settings.
Citation Text:
Jukkala AM, Kirby RS. Challenges faced in providing safe care in rural perinatal settings. MCN Am J Matern Child Nurs. 2009;34(6):365-371. doi:10.1097/01.NMC.0000363685.20315.0e.
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psnet.ahrq.gov/issue/case-improving-measurement-intraoperative-iatrogenic-injuries
February 14, 2017 - Commentary
A case for improving measurement of intraoperative iatrogenic injuries.
Citation Text:
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries. JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
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psnet.ahrq.gov/issue/more-teamwork-knowledge-skill-and-attitude
July 13, 2009 - Study
More to teamwork than knowledge, skill and attitude.
Citation Text:
Siassakos D, Draycott TJ, Crofts JF, et al. More to teamwork than knowledge, skill and attitude. BJOG. 2010;117(10):1262-9. doi:10.1111/j.1471-0528.2010.02654.x.
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psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run
March 21, 2012 - Commentary
Classic
Rapid response teams—walk, don't run.
Citation Text:
Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13). doi:10.1001/jama.296.13.1645.
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psnet.ahrq.gov/issue/what-went-right-lessons-intensivist-crew-us-airways-flight-1549
February 23, 2009 - Commentary
What went right: lessons for the intensivist from the crew of US Airways Flight 1549.
Citation Text:
Eisen LA, Savel RH. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest. 2009;136(3):910-917. doi:10.1378/chest.09-0377.
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psnet.ahrq.gov/issue/risk-management-or-just-different-risk
April 12, 2011 - Study
Risk management, or just a different risk?
Citation Text:
Freer Y, Lyon A. Risk management, or just a different risk? Arch Dis Child Fetal Neonatal Ed. 2006;91(5):F327-9.
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psnet.ahrq.gov/issue/nobody-cared-women-who-have-reported-mistreatment-while-giving-birth-say-cdc-report-validates
April 27, 2022 - Newspaper/Magazine Article
'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.
Citation Text:
'Nobody cared': Women who have reported mistreatment while giving b…
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psnet.ahrq.gov/issue/implementation-protocol-reduce-occurrence-retained-sponges-after-vaginal-delivery
May 18, 2022 - Commentary
Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.
Citation Text:
Lutgendorf MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Mil Med. 2011;176(6):702-704.…
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psnet.ahrq.gov/issue/system-wide-initiative-prevent-retained-vaginal-sponges
November 07, 2012 - Commentary
A system-wide initiative to prevent retained vaginal sponges.
Citation Text:
Chagolla BA, Gibbs VC, Keats JP, et al. A system-wide initiative to prevent retained vaginal sponges. MCN Am J Matern Child Nurs. 2011;36(5):312-317. doi:10.1097/NMC.0b013e31822ab204.
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psnet.ahrq.gov/issue/reducing-risk-maternity-optimising-teamwork-and-leadership-evidence-based-approach-save
January 06, 2016 - Review
Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.
Citation Text:
Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mot…
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psnet.ahrq.gov/issue/tamiflu-oseltamivir-oral-suspension-potential-medication-errors
November 07, 2012 - Government Resource
Tamiflu (oseltamivir) for oral suspension: potential medication errors.
Citation Text:
Tamiflu (oseltamivir) for oral suspension: potential medication errors. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 25, 2009.
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psnet.ahrq.gov/issue/story-behind-story-physician-skepticism-about-relying-clinical-information-technologies
July 14, 2010 - Study
The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.
Citation Text:
McAlearney AS, Chisolm DJ, Schweikhart S, et al. The story behind the story: physician skepticism about relying on clinical information tec…
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psnet.ahrq.gov/issue/you-cant-understand-something-you-hide-transparency-path-improve-patient-safety
October 04, 2006 - Newspaper/Magazine Article
You can't understand something you hide: transparency as a path to improve patient safety.
Citation Text:
You can't understand something you hide: transparency as a path to improve patient safety. Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog. June…