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psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement
January 08, 2020 - Grant Announcement
Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18).
Citation Text:
Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). Rockville, MD: Agency for Healthcare Research and Quality; Septembe…
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psnet.ahrq.gov/issue/cusp-method
October 23, 2019 - Toolkit
The CUSP Method
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The CUSP Method.
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psnet.ahrq.gov/issue/alarm-management-promoting-safety-and-establishing-guidelines
May 24, 2017 - Commentary
Alarm management: promoting safety and establishing guidelines.
Citation Text:
Criscitelli T. Alarm Management: Promoting Safety and Establishing Guidelines. AORN J. 2016;103(5):518-21. doi:10.1016/j.aorn.2016.03.008.
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psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
March 14, 2023 - Newspaper/Magazine Article
Implement strategies to prevent persistent medication errors and hazards.
Citation Text:
Implement strategies to prevent persistent medication errors and hazards. ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Newspaper/Magazine Article
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
Citation Text:
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…
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psnet.ahrq.gov/issue/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines
October 21, 2020 - Newspaper/Magazine Article
Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.
Citation Text:
Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines. ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.
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psnet.ahrq.gov/issue/impact-teamwork-missed-nursing-care
September 27, 2017 - Study
The impact of teamwork on missed nursing care.
Citation Text:
Kalisch BJ, Lee KH. The impact of teamwork on missed nursing care. Nurs Outlook. 2010;58(5):233-41. doi:10.1016/j.outlook.2010.06.004.
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psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
February 06, 2018 - Book/Report
Classic
The Checklist Manifesto: How to Get Things Right.
Citation Text:
The Checklist Manifesto: How to Get Things Right. Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
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psnet.ahrq.gov/issue/errors-omission-missed-nursing-care
September 27, 2017 - Review
Errors of omission: missed nursing care.
Citation Text:
Kalisch BJ, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res. 2014;36(7):875-890. doi:10.1177/0193945914531859.
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psnet.ahrq.gov/issue/overcoming-barriers-patient-safety
September 24, 2016 - Commentary
Overcoming barriers to patient safety.
Citation Text:
Kalisch BJ, Aebersold M. Overcoming barriers to patient safety. Nurs Econ. 2006;24(3):143-8, 155, 123; quiz 149.
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psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century
July 08, 2016 - Book/Report
Classic
Crossing the Quality Chasm: A New Health System for the 21st Century.
Citation Text:
Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: N…
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psnet.ahrq.gov/issue/building-culture-patient-safety-report-commission-patient-safety-and-quality-assurance
November 10, 2011 - Book/Report
Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance.
Citation Text:
Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance. Dublin, Ireland: Department of Health & Childre…
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psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
June 08, 2022 - Commentary
How insight contributes to diagnostic excellence.
Citation Text:
Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311-315. doi:10.1515/dx-2022-0007.
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psnet.ahrq.gov/issue/emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr-downtime
April 20, 2022 - Newspaper/Magazine Article
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.
Citation Text:
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. ISMP Medication Safety Alert! Acute care edition! August 25, 2…
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psnet.ahrq.gov/issue/medication-safety-officers-handbook
September 01, 2018 - Book/Report
Medication Safety Officer's Handbook.
Citation Text:
Medication Safety Officer's Handbook. Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104.
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psnet.ahrq.gov/issue/handbook-perioperative-and-procedural-patient-safety
December 01, 2021 - Book/Report
Handbook of Perioperative and Procedural Patient Safety.
Citation Text:
Handbook of Perioperative and Procedural Patient Safety. Sanchez JA, Higgins RSD, Kent PS, eds. St Louis, MO: Elsevier; 2024. ISBN: 9780323661799.
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psnet.ahrq.gov/issue/wide-heart-monitor-use-tied-missed-alarms
July 19, 2023 - Newspaper/Magazine Article
Wide heart monitor use tied to missed alarms.
Citation Text:
Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use o…
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psnet.ahrq.gov/issue/patient-safety-functions-state-medical-boards-united-states
April 13, 2022 - Commentary
Patient safety functions of state medical boards in the United States.
Citation Text:
Patient safety functions of state medical boards in the United States. Roy CG. Yale J Biol Med. 2021;94(1):165-173.
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psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
December 24, 2007 - Government Resource
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.
Citation Text:
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
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psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems
June 22, 2022 - Commentary
The frustrating case of incident-reporting systems.
Citation Text:
Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. doi:10.1136/qshc.2008.029496.
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