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psnet.ahrq.gov/node/35691/psn-pdf
February 08, 2006 - Recommendations for Safe Use of Insulin in Hospitals.
February 8, 2006
Bethesda MD: American Society of Health-system Pharmacists, Hospital and Health-System Association of
Pennsylvania; 2004.
https://psnet.ahrq.gov/issue/recommendations-safe-use-insulin-hospitals
This report contains recommendations from a panel …
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psnet.ahrq.gov/issue/patient-patient-involvement-strategies-diagnostic-error-mitigation
April 24, 2018 - Review
The patient is in: patient involvement strategies for diagnostic error mitigation.
Citation Text:
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-…
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - first examine the system presently in place.( 7 ) Using a high-level flow diagram may be helpful in determining
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung,
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psnet.ahrq.gov/node/37443/psn-pdf
July 14, 2008 - Medication errors in older people with mental health
problems: a review.
July 14, 2008
doi:10.1002/gps.1943.
https://psnet.ahrq.gov/issue/medication-errors-older-people-mental-health-problems-review
This review sought to determine medication error rates in elderly patients with mental health diagnoses but
found t…
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psnet.ahrq.gov/node/37182/psn-pdf
March 03, 2011 - Getting surgery right.
March 3, 2011
Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246(3):395-403, discussion 403-5.
https://psnet.ahrq.gov/issue/getting-surgery-right
This study examined instances of wrong-site surgery reported to authorities in Pennsylvania and sought to
determine facto…
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psnet.ahrq.gov/node/37421/psn-pdf
February 15, 2011 - Prescription for error: process defects in a community
retail pharmacy.
February 15, 2011
Witte D, Dundes L. Prescription for Error. J Patient Saf. 2008;3(4). doi:10.1097/pts.0b013e31815a613e.
https://psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy
This study used direct observati…
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psnet.ahrq.gov/node/42389/psn-pdf
September 02, 2016 - Report on the ISPE Drug Shortages Survey.
September 2, 2016
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
https://psnet.ahrq.gov/issue/report-ispe-drug-shortages-survey
This worldwide survey determined root causes and underlying issues contributing to drug shortages and
provides recom…
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psnet.ahrq.gov/node/43357/psn-pdf
July 16, 2014 - Wake Up Safe.
July 16, 2014
Society for Pediatric Anesthesia.
https://psnet.ahrq.gov/issue/wake-safe
This Web site provides information about a Patient Safety Organization initiative to develop an adverse
event registry in perioperative care for pediatric patients, determine causes for errors, and design
preventi…
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psnet.ahrq.gov/node/34631/psn-pdf
December 23, 2016 - Sentinel Event Alert.
December 23, 2016
Oakbrook Terrace, IL: The Joint Commission.
https://psnet.ahrq.gov/issue/sentinel-event-alert
This newsletter provides guidance to health care organizations for responding to commonly reported
incidents. The Joint Commission issues these sentinel event alerts to review selec…
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psnet.ahrq.gov/issue/30-day-potentially-avoidable-readmissions-due-adverse-drug-events
June 14, 2017 - Study
30-day potentially avoidable readmissions due to adverse drug events.
Citation Text:
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
Copy Citati…
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psnet.ahrq.gov/node/37944/psn-pdf
April 11, 2011 - Identification of adverse events at an orthopedics
department in Sweden.
April 11, 2011
Unbeck M, Muren O, Lillkrona U. Identification of adverse events at an orthopedics department in Sweden.
Acta Orthop. 2008;79(3):396-403. doi:10.1080/17453670710015319.
https://psnet.ahrq.gov/issue/identification-adverse-events…
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psnet.ahrq.gov/node/34616/psn-pdf
March 28, 2005 - Score Your Safety Culture.
March 28, 2005
Reason J. Flight Safety Australia. 2001;5(1):40-41.
https://psnet.ahrq.gov/issue/score-your-safety-culture
James Reason's checklist to help an organization determine if it has installed and sustained a safety
culture. The tool is drawn from his thinking in Managing the Ris…
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psnet.ahrq.gov/node/35164/psn-pdf
June 23, 2009 - Management of the difficult airway: a closed claims
analysis.
June 23, 2009
Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis.
Anesthesiology. 2005;103(1):33-39.
https://psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
The authors analyze…
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psnet.ahrq.gov/node/39782/psn-pdf
August 25, 2010 - Developing a common language for evaluation questions
in quality and safety improvement.
August 25, 2010
Lambert MF; Shearer H.
https://psnet.ahrq.gov/issue/developing-common-language-evaluation-questions-quality-and-safety-
improvement
This commentary discusses several frameworks for evaluating patient safety an…
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psnet.ahrq.gov/node/35815/psn-pdf
July 21, 2010 - A national survey of obstetric anaesthetic handovers.
July 21, 2010
Sabir N, Yentis SM, Holdcroft A. A national survey of obstetric anaesthetic handovers*. Anaesthesia.
2006;61(4). doi:10.1111/j.1365-2044.2006.04541.x.
https://psnet.ahrq.gov/issue/national-survey-obstetric-anaesthetic-handovers
The researchers sur…
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psnet.ahrq.gov/node/35539/psn-pdf
March 29, 2010 - Differentiating close calls from errors: a multidisciplinary
perspective.
March 29, 2010
Etchegaray JM; Thomas EJ; Geraci JM; Simmons D; Martin SK.
https://psnet.ahrq.gov/issue/differentiating-close-calls-errors-multidisciplinary-perspective
In this AHRQ-funded study, the investigators determined that health care …
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psnet.ahrq.gov/node/38670/psn-pdf
November 25, 2009 - Assessing hospital safety on nights and weekends: the
SWAN tool.
November 25, 2009
Shulkin DJ. Assessing hospital safety on nights and weekends: the SWAN tool. J Patient Saf.
2009;5(2):75-8. doi:10.1097/PTS.0b013e3181a5db10.
https://psnet.ahrq.gov/issue/assessing-hospital-safety-nights-and-weekends-swan-tool
This…
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psnet.ahrq.gov/node/36406/psn-pdf
March 03, 2011 - Nature of human error: implications for surgical practice.
March 3, 2011
Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642-8.
https://psnet.ahrq.gov/issue/nature-human-error-implications-surgical-practice
The authors analyzed the literature to identify important compo…
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psnet.ahrq.gov/node/35247/psn-pdf
December 17, 2008 - Review of the Australian Incident Monitoring System.
December 17, 2008
Spigelman AD, Swan J. Review of the Australian incident monitoring system. ANZ J Surg. 2005;75(8):657-
61.
https://psnet.ahrq.gov/issue/review-australian-incident-monitoring-system
The authors surveyed users of the Australian Incident Monitorin…