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psnet.ahrq.gov/node/72544/psn-pdf
December 09, 2020 - Design and implementation of an analgesia, sedation, and
paralysis order set to enhance compliance of pro re nata
medication orders with Joint Commission medication
management standards in a pediatric ICU.
December 9, 2020
Procaccini D, Rapaport R, Petty BG, et al. Design and Implementation of an analgesia, sedati…
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psnet.ahrq.gov/node/41011/psn-pdf
March 04, 2015 - Ambulatory prescribing errors among community-based
providers in two states.
March 4, 2015
Abramson EL, Bates DW, Jenter CA, et al. Ambulatory prescribing errors among community-based
providers in two states. J Am Med Inform Assoc. 2012;19(4):644-8. doi:10.1136/amiajnl-2011-000345.
https://psnet.ahrq.gov/issue/amb…
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psnet.ahrq.gov/node/45244/psn-pdf
August 01, 2016 - Sleep science, schedules, and safety in hospitals:
challenges and solutions for pediatric providers.
August 1, 2016
Rosenbluth G, Landrigan CP. Sleep science, schedules, and safety in hospitals: challenges and solutions
for pediatric providers. Pediatr Clin North Am. 2012;59(6):1317-28. doi:10.1016/j.pcl.2012.09.00…
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psnet.ahrq.gov/node/46598/psn-pdf
March 20, 2018 - Fatigue risk management: the impact of anesthesiology
residents' work schedules on job performance and a
review of potential countermeasures.
March 20, 2018
Wong LR, Flynn-Evans E, Ruskin KJ. Fatigue Risk Management: The Impact of Anesthesiology Residents'
Work Schedules on Job Performance and a Review of Potentia…
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psnet.ahrq.gov/node/849599/psn-pdf
May 31, 2023 - Racial inequality in receipt of medications for opioid use
disorder.
May 31, 2023
Barnett ML, Meara E, Lewinson T, et al. Racial inequality in receipt of medications for opioid use disorder.
New Engl J Med. 2023;388(19):1779-1789. doi:10.1056/nejmsa2212412.
https://psnet.ahrq.gov/issue/racial-inequality-receipt-me…
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www.ahrq.gov/teamstepps-program/curriculum/implement/index.html
January 01, 2024 - Implementing TeamSTEPPS 3.0 in an Organization or Unit
The primary users of this Implementation section will be individuals or teams responsible for implementing and sustaining the use of TeamSTEPPS concepts or tools within an organization or unit and people equipping them with needed resources. The first part …
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psnet.ahrq.gov/node/60551/psn-pdf
January 01, 2021 - Improvement in patient safety may precede policy
changes: trends in patient safety indicators in the United
States, 2000-2013.
June 3, 2020
Tedesco D, Moghavem N, Weng Y, et al. Improvement in patient safety may precede policy changes:
trends in patient safety indicators in the United States, 2000-2013. J Patient …
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psnet.ahrq.gov/node/43090/psn-pdf
November 23, 2016 - Safety Is Personal: Partnering With Patients and Families
for the Safest Care.
November 23, 2016
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA:
National Patient Safety Foundation; March 2014.
https://psnet.ahrq.gov/issue/safety-personal-partnering-patients-and-families…
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psnet.ahrq.gov/node/45240/psn-pdf
June 15, 2016 - Is technology the best medicine? Three practice
theoretical perspectives on medication administration
technologies in nursing.
June 15, 2016
Boonen MJ, Vosman FJ, Niemeijer AR. Is technology the best medicine? Three practice theoretical
perspectives on medication administration technologies in nursing. Nurs Inq. 2…
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psnet.ahrq.gov/node/40260/psn-pdf
February 08, 2017 - A case for safety leadership team training of hospital
managers.
February 8, 2017
Singer SJ, Hayes J, Cooper JB, et al. A case for safety leadership team training of hospital managers.
Health Care Manage Rev. 2011;36(2):188-200. doi:10.1097/HMR.0b013e318208cd1d.
https://psnet.ahrq.gov/issue/case-safety-leadership-…
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psnet.ahrq.gov/node/36205/psn-pdf
May 27, 2011 - Physician characteristics, attitudes, and use of
computerized order entry.
May 27, 2011
Lindenauer PK, Ling D, Pekow PS, et al. Physician characteristics, attitudes, and use of computerized
order entry. J Hosp Med. 2006;1(4):221-30.
https://psnet.ahrq.gov/issue/physician-characteristics-attitudes-and-use-computeri…
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psnet.ahrq.gov/node/43764/psn-pdf
July 03, 2016 - Redesigning rounds: towards a more purposeful
approach to inpatient teaching and learning.
July 3, 2016
Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to
inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097/ACM.0000000000000579.
https://psnet.ahr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - HHCEB Presentation
*
VTE Prevention:
An Institution-wide Initiative
University of Michigan
Caprini VTE risk assessment
May 20, 2012
Marc Moote, PA-C
Chief Physician Assistant
University of Michigan Health System
*
*
Key Strategies
Scope: ALL adult inpatients
Standardized VTE Protocol – Caprini model
Mandato…
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psnet.ahrq.gov/node/44761/psn-pdf
January 06, 2016 - Two fatal cases of accidental intrathecal vincristine
administration: learning from death events.
January 6, 2016
Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal
vincristine administration: learning from death event. Chemotherapy (Los Angel). 2016;61(2):108-110.
d…
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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/cus.html
May 01, 2023 - Tool: CUS
Using the CUS technique provides another tool for advocacy, assertion, and mutual support. Signs with words such as "danger," "warning," and "caution" are common in the medical arena. They catch the viewer’s attention. In verbal communication, "CUS" and other signal phrases have a similar effect. If a…
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psnet.ahrq.gov/node/36380/psn-pdf
February 28, 2011 - Graduate medical education and patient safety: a busy--
and occasionally hazardous--intersection.
February 28, 2011
Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and
occasionally hazardous--intersection. Ann Intern Med. 2006;145(8):592-8.
https://psnet.ahrq.gov/issue/gra…
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psnet.ahrq.gov/node/40524/psn-pdf
March 04, 2019 - Principles of pediatric patient safety: reducing harm due
to medical care.
March 4, 2019
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to
Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542/peds.2018-3649.
https://psnet.ahrq.gov/issue/principles-pedi…
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psnet.ahrq.gov/node/47415/psn-pdf
December 05, 2018 - Blinding or information control in diagnosis: could it
reduce errors in clinical decision-making?
December 5, 2018
Lockhart JJ, Satya-Murti S. Blinding or information control in diagnosis: could it reduce errors in clinical
decision-making? Diagnosis (Berl). 2018;5(4):179-189. doi:10.1515/dx-2018-0030.
https://psn…
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psnet.ahrq.gov/node/47382/psn-pdf
August 29, 2018 - Parenteral opioid shortage—treating pain during the
opioid-overdose epidemic.
August 29, 2018
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med.
2018;379(7):601-603. doi:10.1056/NEJMp1807117.
https://psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-…
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psnet.ahrq.gov/node/36003/psn-pdf
March 28, 2011 - The "To Err Is Human Report" and the patient safety
literature.
March 28, 2011
Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature.
Qual Saf Health Care. 2006;15(3):174-8.
https://psnet.ahrq.gov/issue/err-human-report-and-patient-safety-literature
This study …