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psnet.ahrq.gov/node/41734/psn-pdf
October 03, 2012 - Prescribing errors in hospital practice.
October 3, 2012
Tully MP. Prescribing errors in hospital practice. Br J Clin Pharmacol. 2012;74(4):668-75.
doi:10.1111/j.1365-2125.2012.04313.x.
https://psnet.ahrq.gov/issue/prescribing-errors-hospital-practice
Highlighting inconsistencies in defining and measuring prescrib…
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psnet.ahrq.gov/node/35699/psn-pdf
November 18, 2011 - Improving the Reliability of Health Care.
November 18, 2011
Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004.
https://psnet.ahrq.gov/issue/improving-reliability-health-care
This report shares a three-step model for applying reliability principles to health care. The element…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Objectives
At the conclusion of this educational activity, participants should be able to:
Define
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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - Neurosurgical trauma call: use
of a mathematical simulation program to define manpower needs.
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psnet.ahrq.gov/node/38426/psn-pdf
February 18, 2009 - Patient safety organizations ready for action.
February 18, 2009
Clancy CM. Patient Safety Organizations ready for action. AORN J. 2009;89(2):385-7.
doi:10.1016/j.aorn.2009.01.017.
https://psnet.ahrq.gov/issue/patient-safety-organizations-ready-action
This commentary discusses the AHRQ rule defining the role of pa…
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psnet.ahrq.gov/node/37198/psn-pdf
October 06, 2011 - Criminalization of medical error: who draws the line?
October 6, 2011
Dekker SWA. Criminalization of medical error: who draws the line? ANZ J Surg. 2007;77(10):831-7.
https://psnet.ahrq.gov/issue/criminalization-medical-error-who-draws-line
The author discusses the complexities of defining and responding to health …
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psnet.ahrq.gov/node/48058/psn-pdf
June 19, 2019 - Organisational learning in hospitals: a concept analysis.
June 19, 2019
Lyman B, Hammond EL, Cox JR. Organisational learning in hospitals: A concept analysis. J Nurs Manag.
2019;27(3):633-646. doi:10.1111/jonm.12722.
https://psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis
Organizations are …
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psnet.ahrq.gov/node/50400/psn-pdf
October 02, 2019 - The role of personal health information management in
promoting patient safety in the home: a qualitative
analysis
October 2, 2019
Demiris G, Lin S-Y, Turner AM. The role of personal health information management in promoting patient
safety in the home: a qualitative analysis. Stud Health Technol Inform . 2019;264…
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psnet.ahrq.gov/node/837701/psn-pdf
July 20, 2022 - Pediatric surgical errors: a systematic scoping review.
July 20, 2022
Marsh KM, Fleming MA, Turrentine FE, et al. Pediatric surgical errors: a systematic scoping review. J
Pediatr Surg. 2022;57(4):616-621. doi:10.1016/j.jpedsurg.2021.07.019.
https://psnet.ahrq.gov/issue/pediatric-surgical-errors-systematic-scoping-…
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psnet.ahrq.gov/node/72852/psn-pdf
March 17, 2021 - Declaring uncertainty: using quality improvement
methods to change the conversation of diagnosis.
March 17, 2021
Ipsaro AJ, Patel SJ, Warner DC, et al. Declaring Uncertainty: Using Quality Improvement Methods to
Change the Conversation of Diagnosis. Hosp Pediatr. 2021;11(4):334-341. doi:10.1542/hpeds.2020-
000174.…
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psnet.ahrq.gov/node/850167/psn-pdf
June 07, 2023 - Perception of feeling safe perioperatively: a concept
analysis.
June 7, 2023
Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Perception of feeling safe perioperatively: a concept
analysis. Int J Qual Stud Health Well-being. 2023;18(1):2216018. doi:10.1080/17482631.2023.2216018.
https://psnet.ahrq.gov/issue/perc…
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psnet.ahrq.gov/node/838256/psn-pdf
October 05, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic
Safety: Pragmatic Recommendations for Nurse Leaders
and Educators.
October 5, 2022
Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2022. AHRQ Publication No. 22-0026-4-EF.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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psnet.ahrq.gov/node/42198/psn-pdf
June 05, 2013 - Returning to the roots of culture: a review and re-
conceptualisation of safety culture.
June 5, 2013
Edwards JRD, Davey J, Armstrong K. Returning to the roots of culture: A review and re-conceptualisation
of safety culture. Saf Sci. 2013;55. doi:10.1016/j.ssci.2013.01.004.
https://psnet.ahrq.gov/issue/returning-r…
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psnet.ahrq.gov/node/40705/psn-pdf
August 17, 2011 - Health Information Technology and Patient Safety: A
Dynamic Discussion.
August 17, 2011
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; May 2011.
https://psnet.ahrq.gov/issue/health-information-technology-and-patient-safety-dynamic-discussion
This report from the Lucian Leape Institut…
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psnet.ahrq.gov/node/45741/psn-pdf
November 16, 2018 - Monitoring the diagnostic process on an inpatient
neurology service.
November 16, 2018
Dhand A, Bucelli R, Varadhachary A, et al. Monitoring the Diagnostic Process on an Inpatient Neurology
Service. Neurohospitalist. 2017;7(3):132-136. doi:10.1177/1941874416677681.
https://psnet.ahrq.gov/issue/monitoring-diagnosti…
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psnet.ahrq.gov/node/42045/psn-pdf
February 13, 2013 - Improving patient safety through the systematic
evaluation of patient outcomes.
February 13, 2013
Forster AJ, Dervin G, Martin C, et al. Improving patient safety through the systematic evaluation of patient
outcomes. Can J Surg. 2012;55(6):418-25. doi:10.1503/cjs.007811.
https://psnet.ahrq.gov/issue/improving-pati…
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psnet.ahrq.gov/node/43295/psn-pdf
June 27, 2018 - Sound the alarm.
June 27, 2018
Addis LM, Cadet VN, Graham KC. Patient Saf Qual Healthc. May/June 2014.
https://psnet.ahrq.gov/issue/sound-alarm
Clinical alarms may contribute to errors due to alarm fatigue. This article describes four key elements to
achieve lasting improvement of alarm safety across organizations…
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psnet.ahrq.gov/node/34617/psn-pdf
March 07, 2005 - World Alliance for Patient Safety: forward programme.
March 7, 2005
Geneva, Switzerland: World Health Organization; 2004.
https://psnet.ahrq.gov/issue/world-alliance-patient-safety-forward-programme
This report outlines the six goals set by the new world alliance to achieve what no single country could
accomplish …
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psnet.ahrq.gov/node/44820/psn-pdf
March 08, 2017 - Patient Safety Project 2015–2017.
March 8, 2017
National Quality Forum; NQF.
https://psnet.ahrq.gov/issue/patient-safety-project-2015-2017
The National Quality Forum (NQF) has been a leader in defining patient safety reporting measures. This
website provides information about the third cycle of an NQF patient safe…