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psnet.ahrq.gov/node/44690/psn-pdf
August 03, 2017 - Distracted practice: a concept analysis.
August 3, 2017
D'Esmond LK. Distracted Practice: A Concept Analysis. Nurs Forum. 2016;51(4):275-285.
doi:10.1111/nuf.12153.
https://psnet.ahrq.gov/issue/distracted-practice-concept-analysis
Distractions are frequent in the acute care environment and can hinder safety of car…
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psnet.ahrq.gov/node/42738/psn-pdf
December 13, 2013 - Patient safety incidents in hospice care: observations
from interdisciplinary case conferences.
December 13, 2013
Oliver DP, Demiris G, Wittenberg-Lyles E, et al. Patient safety incidents in hospice care: observations from
interdisciplinary case conferences. J Palliat Med. 2013;16(12):1561-7. doi:10.1089/jpm.2013.0…
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psnet.ahrq.gov/node/40710/psn-pdf
August 24, 2011 - Challenges in posthospital care: nurses as coaches for
medication management.
August 24, 2011
Costa LL, Poe SS, Lee MC. Challenges in posthospital care: nurses as coaches for medication
management. J Nurs Care Qual. 2011;26(3):243-51. doi:10.1097/NCQ.0b013e31820e1543.
https://psnet.ahrq.gov/issue/challenges-postho…
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psnet.ahrq.gov/node/43574/psn-pdf
October 08, 2014 - The mixed blessings of smart infusion devices and health
care IT.
October 8, 2014
Nemeth CP, Brown J, Crandall B, et al. The mixed blessings of smart infusion devices and health care IT.
Mil Med. 2014;179(8 Suppl):4-10. doi:10.7205/MILMED-D-13-00505.
https://psnet.ahrq.gov/issue/mixed-blessings-smart-infusion-devi…
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psnet.ahrq.gov/node/43165/psn-pdf
May 07, 2014 - Disrespectful behaviors—part 1 and part 2.
May 7, 2014
ISMP Medication Safety Alert! Acute care edition. October 3, 2013;18:1-4. April 24, 2014;19:1-4.
https://psnet.ahrq.gov/issue/disrespectful-behaviors-part-1-and-part-2
The first article of this series reports the results of a survey investigating disruptive beh…
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psnet.ahrq.gov/node/50750/psn-pdf
January 01, 2020 - Patterns in medication incidents: a 10-yr experience of a
cross-national anaesthesia incident reporting system.
December 18, 2019
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr
experience of a cross-national anaesthesia incident reporting system. Br J Anaesth. …
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psnet.ahrq.gov/node/838077/psn-pdf
September 14, 2022 - Healthcare-associated adverse events in alternate level of
care patients awaiting long-term care in hospital.
September 14, 2022
Lim Fat GJ, Gopaul A, Pananos AD, et al. Healthcare-associated adverse events in alternate level of care
patients awaiting long-term care in hospital. Geriatrics (Basel). 2022;7(4):81.
d…
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psnet.ahrq.gov/node/72792/psn-pdf
March 03, 2021 - Avoiding a Med-Wreck: a structured medication
reconciliation framework and standardized auditing tool
utilized to optimize patient safety and reallocate hospital
resources.
March 3, 2021
Elbeddini A, Almasalkhi S, Prabaharan T, et al. Avoiding a Med-Wreck: a structured medication
reconciliation framework and stan…
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psnet.ahrq.gov/node/60194/psn-pdf
April 01, 2020 - Do you know what doses are being programmed in the
OR? Make it an expectation to use smart infusion pumps
with DERS.
April 1, 2020
Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion
pumps with DERS. ISMP Medication Safety Alert! Acute care edition!. 25(5):1-5.
http…
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psnet.ahrq.gov/node/73981/psn-pdf
October 20, 2021 - Medication errors at hospital admission and discharge:
risk factors and impact of medication reconciliation
process to improve healthcare.
October 20, 2021
Breuker C, Macioce V, Mura T, et al. Medication errors at hospital admission and discharge: risk factors
and impact of medication reconciliation process to imp…
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psnet.ahrq.gov/node/848318/psn-pdf
May 03, 2023 - Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care - a qualitative
study on hospital wards.
May 3, 2023
Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care – a qualitative st…
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psnet.ahrq.gov/node/35650/psn-pdf
June 25, 2010 - Am I safe here? Improving patients' perceptions of safety
in hospitals.
June 25, 2010
Wolosin RJ, Vercler L, Matthews JL. Am I safe here?: improving patients' perceptions of safety in hospitals.
J Nurs Care Qual. 2006;21(1):30-40.
https://psnet.ahrq.gov/issue/am-i-safe-here-improving-patients-perceptions-safety-ho…
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psnet.ahrq.gov/node/34646/psn-pdf
July 01, 2015 - The attributes of medical event reporting systems.
July 1, 2015
Battles JB, Kaplan HS, van der Schaaf TW, et al. The attributes of medical event-reporting systems:
experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med.
1998;122(3):231-8.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43527/psn-pdf
September 24, 2014 - The morbidity and mortality conference in PICUs in the
United States: a national survey.
September 24, 2014
Cifra CL, Bembea MM, Fackler JC, et al. The morbidity and mortality conference in PICUs in the United
States: a national survey. Crit Care Med. 2014;42(10):2252-7. doi:10.1097/CCM.0000000000000505.
https://p…
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psnet.ahrq.gov/node/45052/psn-pdf
June 08, 2016 - Mean girls of the ER: the alarming nurse culture of
bullying and hazing.
June 8, 2016
Robbins A. Good Housekeeping. May 20, 2016.
https://psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to med…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - The second column is labeled “Plus” and includes descriptions of the positive or effective characteristics
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psnet.ahrq.gov/node/72774/psn-pdf
February 24, 2021 - Preventable adverse drug events causing hospitalisation:
identifying root causes and developing a surveillance and
learning system at an urban community hospital, a cross-
sectional observational study.
February 24, 2021
de Lemos J, Loewen PS, Nagle C, et al. Preventable adverse drug events causing hospitalisation…
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psnet.ahrq.gov/node/46028/psn-pdf
July 05, 2017 - The role of morbidity and mortality rounds in medical
education: a scoping review.
July 5, 2017
Benassi P, MacGillivray L, Silver I, et al. The role of morbidity and mortality rounds in medical education: a
scoping review. Med Educ. 2017;51(5):469-479. doi:10.1111/medu.13234.
https://psnet.ahrq.gov/issue/role-morb…
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psnet.ahrq.gov/issue/pharmacists-play-key-role-patient-safety
March 29, 2023 - Newspaper/Magazine Article
Pharmacists play key role in patient safety.
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March 6, 2005
Description of a successful model from Duke…