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psnet.ahrq.gov/node/46596/psn-pdf
November 01, 2017 - Infection prevention and control in pediatric ambulatory
settings.
November 1, 2017
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
Patient safety in the ambulatory environme…
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psnet.ahrq.gov/node/41380/psn-pdf
June 20, 2012 - A novel tool for organisational learning and its impact on
safety culture in a hospital dispensary.
June 20, 2012
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.
Reliab Eng Syst Saf. 2012;101:21-34. doi:10.1016/j.ress.2011.12.021.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/34627/psn-pdf
December 08, 2015 - Patient & Worker Safety.
December 8, 2015
Association of periOperative Registered Nurses.
https://psnet.ahrq.gov/issue/patient-worker-safety
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses'
(AORN) patient safety initiative targeting the needs of perioperative …
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psnet.ahrq.gov/node/50664/psn-pdf
November 13, 2019 - Drug Shortages: Root Causes and Potential Solutions.
November 13, 2019
Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020.
https://psnet.ahrq.gov/issue/drug-shortages-root-causes-and-potential-solutions
Drug shortages result from a variety of systemic failures. This report identifies…
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psnet.ahrq.gov/node/36041/psn-pdf
June 21, 2006 - Intraoperative adverse events and related postoperative
complications in spine surgery: implications for
enhancing patient safety founded on evidence-based
protocols.
June 21, 2006
Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG.
https://psnet.ahrq.gov/issue/intraoperative-adverse-…
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psnet.ahrq.gov/node/36158/psn-pdf
September 29, 2010 - Medication therapy management programs: forming a
new cornerstone for quality and safety in Medicare.
September 29, 2010
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality
and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
https://psnet.ahrq.gov/issue/medicatio…
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psnet.ahrq.gov/node/34573/psn-pdf
August 16, 2017 - Medical Errors and Patient Safety: A Curriculum Guide for
Teaching Medical Students and Family Practice
Residents.
August 16, 2017
Halbach JL; Sullivan L; New York Medical College
https://psnet.ahrq.gov/issue/medical-errors-and-patient-safety-curriculum-guide-teaching-medical-students-
and-family
This curriculum…
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psnet.ahrq.gov/node/40004/psn-pdf
February 01, 2011 - Application of failure mode and effect analysis in a
radiology department.
February 1, 2011
Thornton E, Brook OR, Mendiratta-Lala M, et al. Application of Failure Mode and Effect Analysis in a
Radiology Department. RadioGraphics. 2010;31(1):281-293. doi:10.1148/rg.311105018.
https://psnet.ahrq.gov/issue/applicatio…
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psnet.ahrq.gov/node/46281/psn-pdf
January 01, 2021 - Classifying adverse events in the dental office.
September 6, 2017
Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. Classifying Adverse Events in the Dental Office. J
Patient Saf. 2021;17(6):e540-e356. doi:10.1097/PTS.0000000000000407.
https://psnet.ahrq.gov/issue/classifying-adverse-events-dental-office
In this …
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psnet.ahrq.gov/node/42927/psn-pdf
February 05, 2014 - Staff Care: How to Engage Staff in the NHS and Why It
Matters.
February 5, 2014
London, UK: Point of Care Foundation; January 2014.
https://psnet.ahrq.gov/issue/staff-care-how-engage-staff-nhs-and-why-it-matters
The well-being of clinical staff is crucial to ensuring safe care delivery. This report provides result…
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psnet.ahrq.gov/node/41484/psn-pdf
September 26, 2012 - An institution-wide handoff task force to standardise and
improve physician handoffs.
September 26, 2012
Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve
physician handoffs. BMJ Qual Saf. 2012;21(10):863-71.
https://psnet.ahrq.gov/issue/institution-wide-ha…
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psnet.ahrq.gov/node/35083/psn-pdf
March 29, 2007 - Patient Safety: Achieving a New Standard for Care.
March 29, 2007
Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC:
National Academies Press; 2004. ISBN 0309090776.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
This report details findings…
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psnet.ahrq.gov/node/46284/psn-pdf
January 01, 2021 - The consequences of whistle-blowing: an integrative
review.
July 26, 2017
Lim CR, Zhang MWB, Hussain SF, et al. The Consequences of Whistle-blowing: An Integrative Review. J
Patient Saf. 2021;17(6):e497-e502. doi:10.1097/PTS.0000000000000396.
https://psnet.ahrq.gov/issue/consequences-whistle-blowing-integrative-re…
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psnet.ahrq.gov/node/43864/psn-pdf
January 28, 2015 - Starter Kit for Alarm Fatigue.
January 28, 2015
National Association of Clinical Nurse Specialists; NACNS.
https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue
Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit
provides checklists, resources, and implemen…
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psnet.ahrq.gov/node/38701/psn-pdf
June 28, 2011 - Selection of indicators for continuous monitoring of
patient safety: recommendations of the project 'safety
improvement for patients in Europe.'
June 28, 2011
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety:
recommendations of the project 'safety improvement f…
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psnet.ahrq.gov/node/35113/psn-pdf
April 06, 2011 - Medication errors in intravenous drug preparation and
administration: a multicentre audit in the UK, Germany
and France.
April 6, 2011
Cousins DH, Sabatier B, Begue D, et al. Medication errors in intravenous drug preparation and
administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Car…
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psnet.ahrq.gov/node/42184/psn-pdf
December 18, 2013 - Why don't we know whether care is safe?
December 18, 2013
Pham JC, Frick KD, Pronovost P. Why don't we know whether care is safe? Am J Med Qual.
2013;28(6):457-63. doi:10.1177/1062860613479397.
https://psnet.ahrq.gov/issue/why-dont-we-know-whether-care-safe
This commentary discusses barriers to understanding and m…
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psnet.ahrq.gov/node/853075/psn-pdf
August 30, 2023 - Striving for diagnostic excellence.
August 30, 2023
Centor RM, Dhaliwal G. Annals On Call. July 2023.
https://psnet.ahrq.gov/issue/striving-diagnostic-excellence
Diagnostic accuracy requires both cognitive and team-focused skill development. This podcast interview
shares problem-solving tactics that support diagno…
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psnet.ahrq.gov/node/42695/psn-pdf
August 02, 2015 - Composite measures for profiling hospitals on bariatric
surgery performance.
August 2, 2015
Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery
performance. JAMA Surg. 2014;149(1):10-6. doi:10.1001/jamasurg.2013.4109.
https://psnet.ahrq.gov/issue/composite-meas…
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psnet.ahrq.gov/node/44678/psn-pdf
July 05, 2017 - Patient Safety Risk Management Playbook.
July 5, 2017
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook
Proactive risk management is an important component to improving the safety of care. Exploring principles
of high reliabilit…