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psnet.ahrq.gov/node/43463/psn-pdf
October 06, 2016 - Predictors of unit-level medication administration
accuracy: microsystem impacts on medication safety.
October 6, 2016
Donaldson N, Aydin C, Fridman M. Predictors of unit-level medication administration accuracy:
microsystem impacts on medication safety. J Nurs Adm. 2014;44(6):353-61.
doi:10.1097/NNA.0000000000000…
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psnet.ahrq.gov/node/40702/psn-pdf
October 16, 2012 - Accountability for medical error: moving beyond blame to
advocacy.
October 16, 2012
Bell SK, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error: moving beyond blame to
advocacy. Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533.
https://psnet.ahrq.gov/issue/accountability-medical-error-moving…
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psnet.ahrq.gov/node/45493/psn-pdf
December 07, 2016 - The rising frequency of IT blackouts indicates the
increasing relevance of IT emergency concepts to ensure
patient safety.
December 7, 2016
Sax U, Lipprandt M, Röhrig R. The Rising Frequency of IT Blackouts Indicates the Increasing Relevance of
IT Emergency Concepts to Ensure Patient Safety. Yearb Med Inform. 2016…
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psnet.ahrq.gov/node/36853/psn-pdf
June 07, 2016 - Potential drug interactions and duplicate prescriptions
among cancer patients.
June 7, 2016
Riechelmann RP, Tannock IF, Wang L, et al. Potential drug interactions and duplicate prescriptions among
cancer patients. J Natl Cancer Inst. 2007;99(8):592-600.
https://psnet.ahrq.gov/issue/potential-drug-interactions-and-…
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psnet.ahrq.gov/node/848822/psn-pdf
May 10, 2023 - Inappropriate prescriptions of direct oral anticoagulants
(DOACs) in hospitalized patients: a narrative review.
May 10, 2023
van der Horst SFB, van Rein N, van Mens TE, et al. Inappropriate prescriptions of direct oral
anticoagulants (DOACs) in hospitalized patients: a narrative review. Thromb Res. 2023;231:135-140…
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psnet.ahrq.gov/node/50655/psn-pdf
January 01, 2020 - Reflections on implementing a hospital-wide provider-
based electronic inpatient mortality review system:
lessons learnt.
November 13, 2019
Mendu ML, Lu Y, Petersen A, et al. Reflections on implementing a hospital-wide provider-based electronic
inpatient mortality review system: lessons learnt. BMJ Qual Saf. 2020;…
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psnet.ahrq.gov/node/60002/psn-pdf
March 04, 2020 - Reduce the likelihood of patient harm associated with the
use of anticoagulant therapy: commentary from the
Anticoagulation Forum on the Updated Joint Commission
NPSG.03.05.01 Elements of Performance
March 4, 2020
Dager WE, Ansell J, Barnes GD, et al. “Reduce the Likelihood of Patient Harm Associated with the Use …
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex3.html
July 01, 2018 - Guide to Patient and Family Engagement
Exhibit 3. Literature Review Inclusion and Exclusion Criteria
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussion
Next S…
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psnet.ahrq.gov/node/73171/psn-pdf
April 21, 2021 - Patient safety and quality improvement adaptation during
the COVID-19 pandemic.
April 21, 2021
Sterling RS, Berry SA, Herzke C, et al. Patient safety and quality improvement adaptation during the
COVID-19 pandemic. Am J Med Qual. 2021;36(1):57-59. doi:10.1097/01.jmq.0000733448.50484.a8.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/854385/psn-pdf
October 11, 2023 - Perioperative team-based morbidity and mortality
conferences: a systematic review of the literature.
October 11, 2023
Samost-Williams A, Rosen R, Hannenberg A, et al. Perioperative team-based morbidity and mortality
conferences: a systematic review of the literature. Ann Surg Open. 2023;4(3):e321.
doi:10.1097/as9.…
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psnet.ahrq.gov/node/40025/psn-pdf
December 21, 2014 - Evaluating an evidence-based bundle for preventing
surgical site infection.
December 21, 2014
Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical
site infection: a randomized trial. Arch Surg. 2011;146(3):263-9. doi:10.1001/archsurg.2010.249.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/42379/psn-pdf
August 08, 2013 - Prevalence and nature of adverse medical device events
in hospitalized children.
August 8, 2013
Brady PW, Varadarajan K, Peterson LE, et al. Prevalence and nature of adverse medical device events in
hospitalized children. J Hosp Med. 2013;8(7):390-3. doi:10.1002/jhm.2058.
https://psnet.ahrq.gov/issue/prevalence-an…
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psnet.ahrq.gov/node/41646/psn-pdf
September 05, 2012 - Interventions to increase clinical incident reporting in
health care.
September 5, 2012
Parmelli E, Flodgren G, Fraser SG, et al. Interventions to increase clinical incident reporting in health care.
Cochrane Database Syst Rev. 2012;8(8):CD005609. doi:10.1002/14651858.cd005609.pub2.
https://psnet.ahrq.gov/issue/in…
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psnet.ahrq.gov/node/34968/psn-pdf
July 10, 2008 - Effect of antiseptic handwashing vs alcohol sanitizer on
health care-associated infections in neonatal intensive
care units.
July 10, 2008
Larson EL, Cimiotti JP, Haas JP, et al. Effect of antiseptic handwashing vs alcohol sanitizer on health care-
associated infections in neonatal intensive care units. Arch Pedia…
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psnet.ahrq.gov/node/46093/psn-pdf
April 26, 2017 - Inpatient Notes: human factors engineering and inpatient
care—new ways to solve old problems.
April 26, 2017
Clack L, Sax H. Web Exclusives. Annals for Hospitalists Inpatient Notes - Human Factors Engineering and
Inpatient Care-New Ways to Solve Old Problems. Ann Intern Med. 2017;166(8):HO2-HO3.
doi:10.7326/M17-05…
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psnet.ahrq.gov/node/41043/psn-pdf
May 24, 2012 - Toward improving patient safety through voluntary peer-
to-peer assessment.
May 24, 2012
Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-
to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981.
https://psnet.ahrq.gov/issue/toward-impr…
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh5.html
August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events
Exhibit 5. Consumer reporting systems inputs and analytic capabilities
Previous Page
Table of Contents
Designing Consumer Reporting Systems for Patient Safety Events
Executive Summary
Chapter 1. Background
Chapter 2. Conceptual F…
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psnet.ahrq.gov/node/74141/psn-pdf
December 01, 2021 - Incident reporting systems: what will it take to make them
less frustrating and achieve anything useful?
December 1, 2021
Shojania KG. Incident reporting systems: what will it take to make them less frustrating and achieve
anything useful? Jt Comm J Qual Patient Saf. 2021;47(12):755-758. doi:10.1016/j.jcjq.2021.10.…
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psnet.ahrq.gov/node/72658/psn-pdf
January 20, 2021 - “I made a mistake!”: a narrative analysis of experienced
physicians' stories of preventable error.
January 20, 2021
Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced
physicians' stories of preventable error. J Eval Clin Pract. 2021;27(2):236-245. doi:10.1111/jep.1353…
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psnet.ahrq.gov/node/45103/psn-pdf
October 06, 2016 - Use of personal electronic devices by nurse anesthetists
and the effects on patient safety.
October 6, 2016
Snoots LR, Wands BA. Use of Personal Electronic Devices by Nurse Anesthetists and the Effects on
Patient Safety. AANA J. 2016;84(2):114-119.
https://psnet.ahrq.gov/issue/use-personal-electronic-devices-nurse…