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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/38448/psn-pdf
March 04, 2009 - Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised
patients.
March 4, 2009
van Doormaal JE, van den Bemt PMLA, Mol PGM, et al. Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised patients. Qual Saf Health Car…
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psnet.ahrq.gov/node/36433/psn-pdf
February 10, 2011 - Effects of computer-based clinical decision support
systems on physician performance and patient outcomes:
a systematic review.
February 10, 2011
Hunt DL, Haynes RB, Hanna SE, et al. Effects of Computer-Based Clinical Decision Support Systems on
Physician Performance and Patient Outcomes. JAMA. 2003;280(15):1339-1…
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psnet.ahrq.gov/node/45971/psn-pdf
April 21, 2018 - Guide to Improving Patient Safety in Primary Care
Settings by Engaging Patients and Families.
April 21, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
https://psnet.ahrq.gov/issue/guide-improving-patient-safety-primary-care-settings-engaging-patients-and-
families
Patient engagement i…
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psnet.ahrq.gov/node/46054/psn-pdf
January 01, 2021 - Misuse of pediatric medications and parent–physician
communication: an interactive voice response
intervention.
April 12, 2017
Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician
Communication: An Interactive Voice Response Intervention. J Patient Saf. 2021;17(3):e177-e185.
…
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psnet.ahrq.gov/node/47423/psn-pdf
January 27, 2019 - A health system–wide initiative to decrease opioid-related
morbidity and mortality.
January 27, 2019
Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related
Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003.
https://psnet.…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/836753/psn-pdf
March 16, 2022 - Inequities in quality and safety outcomes for hospitalized
children with intellectual disability.
March 16, 2022
Mimmo L, Harrison R, Travaglia J, et al. Inequities in quality and safety outcomes for hospitalized children
with intellectual disability. Dev Med Child Neurol. 2022;64(3):314-322. doi:10.1111/dmcn.15066…
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psnet.ahrq.gov/node/45687/psn-pdf
October 31, 2017 - Determining current insulin pen use practices and errors
in the inpatient setting.
October 31, 2017
Brown KE, Hertig JB. Determining Current Insulin Pen Use Practices and Errors in the Inpatient Setting. Jt
Comm J Qual Patient Saf. 2016;42(12):568-AP7. doi:10.1016/S1553-7250(16)30109-X.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/838644/psn-pdf
October 19, 2022 - Golden State Medical Supply, Inc. Issues a Voluntary
Nationwide Recall of Atenolol 25 mg Tablets and
Clopidogrel 75 mg Tablets Due to a Label Mix-up.
October 19, 2022
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.
https://psnet.ahrq.gov/issue/golden-state-medical-sup…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/43175/psn-pdf
December 12, 2014 - Interventions to improve safe and effective medicines use
by consumers: an overview of systematic reviews.
December 12, 2014
Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by
consumers: an overview of systematic reviews. Cochrane Database Syst Rev. 2014;(4):CD007768.
d…
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psnet.ahrq.gov/node/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…
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psnet.ahrq.gov/node/866855/psn-pdf
October 02, 2024 - Reduction in preventable time-critical dose omissions:
impact of electronic medication management systems on
in-patients.
October 2, 2024
Graudins LV, Crute S, Poole SG, et al. Reduction in preventable time-critical dose omissions: impact of
electronic medication management systems on in-patients. Contemp Nurse. 2…
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psnet.ahrq.gov/node/50823/psn-pdf
January 22, 2020 - Reducing inappropriate polypharmacy in primary care
through pharmacy-led interventions.
January 22, 2020
Bryant E, Claire K, Needham R. Reducing inappropriate polypharmacy in primary care through pharmacy-
led interventions. Pharm J. 2019;303(7932). doi:10.1211/pj.2019.20207385.
https://psnet.ahrq.gov/issue/reduci…
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psnet.ahrq.gov/node/844759/psn-pdf
September 18, 2019 - Saving Patient Ryan- can advanced electronic medical
records make patient care safer?
September 18, 2019
Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059.
https://psnet.ahrq.gov/issue/saving-patient-ryan-can-advanced-electronic-medical-records-make-patient-
care-safer
This observational study examin…
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psnet.ahrq.gov/node/60950/psn-pdf
September 23, 2020 - An effective intervention: limiting opioid prescribing as a
means of reducing opioid analgesic misuse, and
overdose deaths.
September 23, 2020
Fink BC, Uyttebrouck O, Larson RS. An effective intervention: limiting opioid prescribing as a means of
reducing opioid analgesic misuse, and overdose deaths. J Law Med Eth…
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psnet.ahrq.gov/node/60724/psn-pdf
July 29, 2020 - The safety of health care for ethnic minority patients: a
systematic review.
July 29, 2020
Chauhan A, Walton M, Manias E, et al. The safety of health care for ethnic minority patients: a systematic
review. Int J Equity Health. 2020;19(1):118. doi:10.1186/s12939-020-01223-2.
https://psnet.ahrq.gov/issue/safety-heal…
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psnet.ahrq.gov/node/60046/psn-pdf
March 18, 2020 - Adverse outcomes of polypharmacy in older people:
systematic review of reviews.
March 18, 2020
Davies LE, Spiers G, Kingston A, et al. Adverse outcomes of polypharmacy in older people: systematic
review of reviews. J Am Med Dir Assoc. 2020;21(2):181-187. doi:10.1016/j.jamda.2019.10.022.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47277/psn-pdf
August 08, 2018 - Students have a key role in a culture of safety: analysis of
student-associated medication incidents.
August 8, 2018
ISMP Medication Safety Alert! Acute care edition. July 26, 2018;23:1-4.
https://psnet.ahrq.gov/issue/students-have-key-role-culture-safety-analysis-student-associated-medication-
incidents
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