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psnet.ahrq.gov/issue/factors-associated-barcode-medication-administration-technology-contribute-patient-safety
September 28, 2010 - Review
Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.
Citation Text:
Strudwick G, Reisdorfer E, Warnock C, et al. Factors Associated With Barcode Medication Administration Technology That Contribute to Patien…
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psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2017
September 30, 2020 - Study
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017.
Citation Text:
Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration-2017. Am J Health Syst Pharm.…
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psnet.ahrq.gov/issue/just-time-training-high-risk-low-volume-therapies-approach-ensure-patient-safety
April 24, 2018 - Commentary
Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety.
Citation Text:
Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-…
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psnet.ahrq.gov/issue/race-and-clinical-diagnosis-depression-new-primary-care-patients
October 21, 2020 - Study
Race and the clinical diagnosis of depression in new primary care patients.
Citation Text:
Lukachko A, Olfson M. Race and the clinical diagnosis of depression in new primary care patients. Gen Hosp Psychiatry. 2011;34(1):98-100. doi:10.1016/j.genhosppsych.2011.09.008.
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/issue/missed-diagnosis-new-onset-systolic-heart-failure-first-presentation-children-no-known-heart
August 18, 2021 - Study
Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease.
Citation Text:
Puri K, Singh H, Denfield SW, et al. Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease…
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psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
September 08, 2021 - Study
Safety climate associated with adverse events in nursing homes: a national VA study.
Citation Text:
Quach ED, Kazis LE, Zhao S, et al. Safety climate associated with adverse events in nursing homes: a national VA study. J Am Med Dir Assoc. 2021;22(2):388-392. doi:10.1016/j.jamda.20…
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psnet.ahrq.gov/issue/bias-warp-speed-how-ai-may-contribute-disparities-gap-time-covid-19
July 22, 2020 - Commentary
Bias at warp speed: how AI may contribute to the disparities gap in the time of COVID-19.
Citation Text:
Röösli E, Rice B, Hernandez-Boussard T. Bias at Warp Speed: How AI may Contribute to the Disparities Gap in the Time of COVID-19. J Am Med Inform Assoc. 2021;28(1):190-192.…
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psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube
May 13, 2020 - Study
Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.
Citation Text:
Farrell C‐JL, Giannoutsos J. Machine learning models outperform manual result review for the identification of wrong blood in…
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psnet.ahrq.gov/issue/final-report-prioritization-patient-safety-practices-new-rapid-review-or-rapid-response
December 21, 2022 - Book/Report
Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.
Citation Text:
Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer …
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psnet.ahrq.gov/issue/implementation-sustainment-large-scale-adverse-event-disclosure-support-program-generated
March 26, 2015 - Study
From implementation to sustainment: a large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration.
Citation Text:
Elwy AR, Maguire EM, McCullough M, et al. From implementation to sustainment: a large-scale adverse e…
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psnet.ahrq.gov/issue/perceptions-nurses-towards-barriers-safe-administration-medicines-mental-health-settings
October 30, 2013 - Study
The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.
Citation Text:
Hemingway S, McCann T, Baxter H, et al. The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings. Int J N…
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psnet.ahrq.gov/issue/temporal-clustering-critical-illness-events-medical-wards
January 31, 2024 - Study
Temporal clustering of critical illness events on medical wards.
Citation Text:
Doshi S, Shin S, Lapointe-Shaw L, et al. Temporal clustering of critical illness events on medical wards. JAMA Intern Med. 2023;183(9):924-932. doi:10.1001/jamainternmed.2023.2629.
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psnet.ahrq.gov/issue/usability-and-safety-analysis-electronic-health-records-multi-center-study
October 13, 2018 - Study
Emerging Classic
A usability and safety analysis of electronic health records: a multi-center study.
Citation Text:
Ratwani RM, Savage E, Will A, et al. A usability and safety analysis of electronic health records: a multi-center study. J Am Med Inform Ass…
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psnet.ahrq.gov/issue/improving-patient-safety-handover-intensive-care-unit-general-ward-systematic-review
June 12, 2008 - Review
Improving patient safety in handover from intensive care unit to general ward: a systematic review.
Citation Text:
Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review. J Patient Saf. 2020;16(3):199-210. doi:10.1…
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psnet.ahrq.gov/issue/using-social-and-behavioural-science-support-covid-19-pandemic-response
March 02, 2022 - Commentary
Classic
Using social and behavioural science to support COVID-19 pandemic response.
Citation Text:
Bavel JJV, Baicker K, Boggio PS, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav. 2020;4(5):460-471. do…
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psnet.ahrq.gov/issue/inaccurate-penicillin-allergy-labeling-electronic-health-record-and-adverse-outcomes-care
December 09, 2020 - Commentary
Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.
Citation Text:
Olans RD, Olans RN, Marfatia R, et al. Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. Jt Comm J Qual Patient …
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psnet.ahrq.gov/issue/contributory-factors-and-patient-harm-including-deaths-associated-direct-acting-oral
January 12, 2022 - Study
Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.
Citation Text:
Rowily AA, Jalal Z, Paudyal V. Contributory factors…