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psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-within-veterans-health-administration
November 06, 2019 - Congressional Testimony
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.
Citation Text:
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration. US House of Representatives Committee on Veterans' Affa…
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psnet.ahrq.gov/issue/microanalysis-video-operating-room-underused-approach-patient-safety-research
January 22, 2014 - Study
Microanalysis of video from the operating room: an underused approach to patient safety research.
Citation Text:
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-…
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psnet.ahrq.gov/issue/alarm-fatigue-use-evidence-based-alarm-management-strategy
July 24, 2024 - Commentary
Alarm fatigue: use of an evidence-based alarm management strategy.
Citation Text:
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue. J Nurs Care Qual. 2016;32(1):47-54. doi:10.1097/ncq.0000000000000223.
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psnet.ahrq.gov/issue/pediatric-medication-errors-postanesthesia-care-unit-analysis-medmarx-data
January 06, 2017 - Study
Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data.
Citation Text:
Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4.
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psnet.ahrq.gov/issue/black-patients-are-more-likely-white-patients-be-hospitals-worse-patient-safety-conditions
August 18, 2021 - Book/Report
Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions.
Citation Text:
Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions. Gangopadhyaya A. Washington DC: Urban Institu…
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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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digital.ahrq.gov/type-care/behavioral-health
January 01, 2023 - Behavioral Health
Empower NICU - A Bridge to Resources for Adjusting and Coping with Emotions (EmBRACE)
Description
This research will develop, evaluate, and test the efficacy of Empower NICU – A Bridge to Resources for Adjusting and Coping with Emotions (EmBRACE), a mobile he…
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psnet.ahrq.gov/issue/underappreciated-role-habit-highly-reliable-healthcare
April 25, 2016 - Commentary
The underappreciated role of habit in highly reliable healthcare.
Citation Text:
Vogus TJ, Hilligoss B. The underappreciated role of habit in highly reliable healthcare. BMJ Qual Saf. 2016;25(3):141-6. doi:10.1136/bmjqs-2015-004512.
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digital.ahrq.gov/program-overview/research-reports/2021-year-review
January 01, 2021 - Improving Healthcare Through AHRQ's Digital Healthcare Research Program: 2021 Year in Review
Executive Summary
"The Digital Healthcare Research Program funds research to create actionable findings around 'what and how digital healthcare technologies work best' for its key stakehold…
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psnet.ahrq.gov/issue/fda-alerts-health-care-providers-compounders-and-patients-dosing-errors-associated-compounded
February 15, 2024 - Press Release/Announcement
FDA alerts health care providers, compounders and patients of dosing errors associated with compounded injectable semaglutide products.
Citation Text:
FDA alerts health care providers, compounders and patients of dosing errors associated with compounded injecta…
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psnet.ahrq.gov/issue/assessment-dod-wounded-warrior-matters-managing-risks-multiple-medications
March 16, 2022 - Government Resource
Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.
Citation Text:
Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications. Alexandria, VA: Department of Defense, Office of the Inspector General; February 21…
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psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-sars-cov-2-letter-clinical
April 08, 2020 - Press Release/Announcement
Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory staff and health care providers.
Citation Text:
Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--l…
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psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
August 07, 2018 - Book/Report
With Safety in Mind: Mental Health Services and Patient Safety.
Citation Text:
With Safety in Mind: Mental Health Services and Patient Safety. Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006.
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psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
October 12, 2022 - Book/Report
Diagnosis: Reducing Errors and Improving Quality.
Citation Text:
Diagnosis: Reducing Errors and Improving Quality. Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022
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psnet.ahrq.gov/issue/improving-pathologists-communication-skills
May 18, 2022 - Commentary
Improving pathologists' communication skills.
Citation Text:
Dintzis SM. Improving Pathologists' Communication Skills. AMA J Ethics. 2016;18(8):802-8. doi:10.1001/journalofethics.2016.18.8.medu1-1608.
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psnet.ahrq.gov/issue/prevention-fatal-opioid-overdose
October 03, 2018 - Commentary
Prevention of fatal opioid overdose.
Citation Text:
Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863-4. doi:10.1001/jama.2012.14205.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/issue/pharmacist-physician-relationship-detection-ambulatory-medication-errors
September 30, 2020 - Study
The pharmacist-physician relationship in the detection of ambulatory medication errors.
Citation Text:
Brown A, Bailey JH, Lee J, et al. The pharmacist-physician relationship in the detection of ambulatory medication errors. Am J Med Sci. 2006;331(1):22-24.
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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digital.ahrq.gov/program-overview/research-reports/2021-year-review/research-overview
January 01, 2021 - Research Overview
Digital healthcare knowledge and tools can enhance the efforts of patients, clinicians, and health systems working to improve healthcare quality and safety. AHRQ’s DHR program funds research to create actionable findings on what and how digital healthcare works best for t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…