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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
March 05, 2008 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach
Improving Error Reporting in Ambulatory
Pediatrics with a Team Approach
Daniel R. Neuspiel, MD, MPH; Margo Guzman, RN, MSN; Cari Harewood, MPA
Abstract
Objective: We aimed to determine the effectiveness of team-based reporting, system…
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www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication
September 28, 2021 - Administration released a safety drug communication warning that the use of nonsteroidal anti-inflammatory drugs
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psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - National incidence of medication error in surgical patients
before and after Accreditation Council for Graduate
Medical Education duty-hour reform.
January 22, 2016
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients
Before and After Accreditation Council for Gra…
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psnet.ahrq.gov/node/45156/psn-pdf
June 22, 2017 - Workarounds to hospital electronic prescribing systems:
a qualitative study in English hospitals.
June 22, 2017
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative
study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551. doi:10.1136/bmjqs-2015-005149.
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February 15, 2023 - Intended and unintended consequences: changes in
opioid prescribing practices for postsurgical, acute, and
chronic pain indications following two policies in North
Carolina, 2012-2018 - controlled and single-series
interrupted time series analyses.
February 15, 2023
Maierhofer CN, Ranapurwala SI, DiPrete BL, et a…
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psnet.ahrq.gov/node/47578/psn-pdf
November 28, 2018 - Identifying electronic health record usability and safety
challenges in pediatric settings.
November 28, 2018
Ratwani RM, Savage E, Will A, et al. Identifying Electronic Health Record Usability And Safety Challenges
In Pediatric Settings. Health Aff (Millwood). 2018;37(11):1752-1759. doi:10.1377/hlthaff.2018.0699.
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December 22, 2017 - A comparison of medication administration errors from
original medication packaging and multi-compartment
compliance aids in care homes: a prospective
observational study.
December 22, 2017
Gilmartin-Thomas JF-M, Smith F, Wolfe R, et al. A comparison of medication administration errors from
original medication pa…
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psnet.ahrq.gov/node/39139/psn-pdf
June 02, 2010 - Assessing resident safety culture in nursing homes:
using the nursing home survey on resident safety.
June 2, 2010
Castle NG, Wagner LM, Perera S, et al. Assessing Resident Safety Culture in Nursing Homes. J Patient
Saf. 2010;64(2):59-67. doi:10.1097/pts.0b013e3181bc05fc.
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psnet.ahrq.gov/node/44374/psn-pdf
August 12, 2015 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2014.
August 12, 2015
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration--2014. Am J Health Syst Pharm. 2015;72(13):1119-37.
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psnet.ahrq.gov/node/45976/psn-pdf
December 21, 2017 - Incidence of clinically relevant medication errors in the
era of electronically prepopulated medication
reconciliation forms: a retrospective chart review.
December 21, 2017
Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of
electronically prepopulated medicatio…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/46404/psn-pdf
December 07, 2017 - Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum.
December 7, 2017
Lipitz-Snyderman A, Pfister D, Classen D, et al. Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum. Cancer. 2017;123(23):4728-4736. doi:10.1002/…
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psnet.ahrq.gov/node/47152/psn-pdf
October 12, 2018 - A quality initiative: a system-wide reduction in serious
medication events through targeted simulation training.
October 12, 2018
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious
Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330…
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psnet.ahrq.gov/node/45207/psn-pdf
August 17, 2016 - Unit-based incident reporting and root cause analysis:
variation at three hospital unit types.
August 17, 2016
Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at
three hospital unit types. BMJ Open. 2016;6(6):e011277. doi:10.1136/bmjopen-2016-011277.
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psnet.ahrq.gov/node/39583/psn-pdf
October 30, 2010 - The harm susceptibility model: a method to prioritise
risks identified in patient safety reporting systems.
October 30, 2010
Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks
identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5.
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psnet.ahrq.gov/node/46612/psn-pdf
February 22, 2018 - Influencing organisational culture to improve hospital
performance in care of patients with acute myocardial
infarction: a mixed-methods intervention study.
February 22, 2018
Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital
performance in care of patients with acute …
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psnet.ahrq.gov/issue/dangerous-infections-are-more-likely-pediatric-intensive-care-units
December 18, 2019 - Newspaper/Magazine Article
Dangerous infections are more likely in pediatric intensive-care units.
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February 15, 2012
Consumer Re…
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psnet.ahrq.gov/node/43016/psn-pdf
May 28, 2014 - Identification of serious and reportable events in home
care: a Delphi survey to develop consensus.
May 28, 2014
Doran DM, Baker R, Szabo C, et al. Identification of serious and reportable events in home care: a Delphi
survey to develop consensus. Int J Health Care Qual. 2014;26(2):136-143. doi:10.1093/intqhc/mzu00…
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psnet.ahrq.gov/node/47603/psn-pdf
March 20, 2019 - Electronic patient identification for sample labeling
reduces wrong blood in tube errors.
March 20, 2019
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong
blood in tube errors. Transfusion (Paris). 2019;59(3):972-980. doi:10.1111/trf.15102.
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