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psnet.ahrq.gov/issue/safety-design
March 11, 2009 - Special or Theme Issue
Safety by Design.
Citation Text:
Safety by Design. Qual Saf Health Care. 2006 Dec;15(Suppl 1):i1-90.
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psnet.ahrq.gov/issue/use-barcode-scanning-prevent-errors-enteral-nutrition-feedings
December 04, 2024 - Newspaper/Magazine Article
Use barcode scanning to prevent errors with enteral nutrition feedings.
Citation Text:
Use barcode scanning to prevent errors with enteral nutrition feedings. ISMP Medication Safety Alert! Acute Care. August 08, 2024;29(16).
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psnet.ahrq.gov/issue/science-teamwork
May 01, 2013 - Special or Theme Issue
The Science of Teamwork.
Citation Text:
The Science of Teamwork. McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.
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psnet.ahrq.gov/issue/diagnostic-excellence-0
December 08, 2021 - Special or Theme Issue
Diagnostic Excellence.
Citation Text:
Diagnostic Excellence. JAMA. Nov 2021-Sep 2022.
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psnet.ahrq.gov/node/842435/psn-pdf
January 26, 2023 - Driving Learning and Improvement After RCA2 Event
Reviews.
January 11, 2023
Collaborative for Accountability and Improvement. January 26, 2023.
https://psnet.ahrq.gov/issue/driving-learning-and-improvement-after-rca2-event-reviews
Root cause analysis (RCA) is a recognized approach to examining failures by identify…
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psnet.ahrq.gov/node/35541/psn-pdf
March 29, 2010 - Feasibility first: developing public performance indicators
on patient safety and clinical effectiveness for Dutch
hospitals.
March 29, 2010
Berg M, Meijerink Y, Gras M, et al. Feasibility first: developing public performance indicators on patient
safety and clinical effectiveness for Dutch hospitals. Health Polic…
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - Diuretics and Electrolyte Abnormalities
Citation Text:
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - more savvy thinking about how to do this research, we can also think about how to use that to more effectively
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psnet.ahrq.gov/node/60538/psn-pdf
May 27, 2020 - Diagnostic Safety Toolkit.
May 27, 2020
Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital
Association. May 2020.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit
Effective communication is an important component of diagnostic accuracy. Shaped with data co…
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psnet.ahrq.gov/node/36051/psn-pdf
January 05, 2017 - Using HFMEA to assess potential for patient harm from
tubing misconnections.
January 5, 2017
Kimehi-Woods J, Shultz JP. Using HFMEA to assess potential for patient harm from tubing
misconnections. Jt Comm J Qual Patient Saf. 2006;32(7):373-381.
https://psnet.ahrq.gov/issue/using-hfmea-assess-potential-patient-harm…
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psnet.ahrq.gov/node/44600/psn-pdf
December 09, 2015 - Systematic review of patient safety interventions in
dentistry.
December 9, 2015
Bailey E, Tickle M, Campbell S, et al. Systematic review of patient safety interventions in dentistry. BMC
Oral Health. 2015;15:152. doi:10.1186/s12903-015-0136-1.
https://psnet.ahrq.gov/issue/systematic-review-patient-safety-interven…
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psnet.ahrq.gov/node/72732/psn-pdf
February 10, 2021 - Health care workers in the midst of crisis.
February 10, 2021
Sentinel Event Alert. Feb 2, 2021;(62):1-7.
https://psnet.ahrq.gov/issue/health-care-workers-midst-crisis
Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational
conditions and supporting the wellb…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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psnet.ahrq.gov/node/41102/psn-pdf
February 01, 2012 - Medication administration errors for older people in long-
term residential care.
February 1, 2012
Szczepura A, Wild D, Nelson S. Medication administration errors for older people in long-term residential
care. BMC Geriatr. 2011;11:82. doi:10.1186/1471-2318-11-82.
https://psnet.ahrq.gov/issue/medication-administra…
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psnet.ahrq.gov/node/841197/psn-pdf
December 07, 2022 - Does malpractice liability promote patient safety? A
methodological excursion.
December 7, 2022
Saks MJ, Landsman S. Jurimetrics. 2022;62:397-419.
https://psnet.ahrq.gov/issue/does-malpractice-liability-promote-patient-safety-methodological-excursion
Malpractice liability is an unconfirmed driver for safety. This …
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psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - The misery of a doctor's first days.
October 14, 2015
Hester JL. The Atlantic. October 1, 2015.
https://psnet.ahrq.gov/issue/misery-doctors-first-days
Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine
the difficulties associated with the first days of pra…
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psnet.ahrq.gov/node/39516/psn-pdf
June 27, 2011 - Risk and pharmacoeconomic analyses of the injectable
medication process in the paediatric and neonatal
intensive care units.
June 27, 2011
De Giorgi I, Fonzo-Christe C, Cingria L, et al. Risk and pharmacoeconomic analyses of the injectable
medication process in the paediatric and neonatal intensive care units. Int…
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psnet.ahrq.gov/node/48054/psn-pdf
June 26, 2019 - Lessons learned from a death outside a hospital's
doorstep.
June 26, 2019
Palmer J. Patient Saf Qual Healthc. May/June 2019.
https://psnet.ahrq.gov/issue/lessons-learned-death-outside-hospitals-doorstep
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be
learned f…