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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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integrationacademy.ahrq.gov/print/pdf/node/23255
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Website
https://bipartisanpolicy.org/?query=behavioral%20health%20integration
Mission
To build connections, negotiate policy, achieve bipartisan solutions, and improve lives.
Location
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Description
A nonprofit that ensures p…
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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - Governing the safety of artificial intelligence in
healthcare.
May 20, 2019
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498.
doi:10.1136/bmjqs-2019-009484.
https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risk…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-informatics-system-enhance-health-care-rural-communities/citation/understanding
January 01, 2023 - Understanding adoption of a personal health record in rural health care clinics: revealing barriers and facilitators of adoption including attributions about potential patient portal users and self-reported characteristics of early adopting users.
Citation
Butler JM, Carter M, Hayden C, et al. Underst…
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digital.ahrq.gov/ahrq-funded-projects/safety-through-enhanced-e-prescribing-tools-stepstools-developing-web-services/final-report
January 01, 2023 - STEPStools: Developing Web Services for Safe Pediatric Dosing - Final Report
Citation
Johnson KB, Gadd Cynthia, Weinberg Stuart, et. al. STEPStools: Developing Web Services for Safe Pediatric Dosing - Final Report. (Prepared by Vanderbilt University Medical Center under Grant No. R18 HS017216). Rockvi…
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psnet.ahrq.gov/node/74093/psn-pdf
November 17, 2021 - Prevent errors during emergency use of hypertonic
sodium chloride solutions.
November 17, 2021
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
Delays in diagnosis and treatment duri…
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psnet.ahrq.gov/node/45567/psn-pdf
October 12, 2016 - Insulin Pens Devices.
October 12, 2016
Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47.
https://psnet.ahrq.gov/issue/insulin-pens-devices
As a high-alert medication, insulin has the potential to result in serious patient harm if administered
incorrectly. Articles in this special issue discuss recommendations de…
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psnet.ahrq.gov/node/43082/psn-pdf
April 16, 2014 - Improving code team performance and survival
outcomes: implementation of pediatric resuscitation team
training.
April 16, 2014
Knight LJ, Gabhart JM, Earnest KS, et al. Improving code team performance and survival outcomes:
implementation of pediatric resuscitation team training. Crit Care Med. 2014;42(2):243-251.…
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psnet.ahrq.gov/node/854265/psn-pdf
October 04, 2023 - Can AI help doctors come up with better diagnoses?
October 4, 2023
Landro L. Wall Street Journal. September 24, 2023.
https://psnet.ahrq.gov/issue/can-ai-help-doctors-come-better-diagnoses
Artificial intelligence (AI) is being considered as a strong contender in the effort to reduce harmful
diagnostic error, but c…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/42135/psn-pdf
April 22, 2013 - Interprofessional education in team communication:
working together to improve patient safety.
April 22, 2013
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working
together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi:10.1136/bmjqs-2012-000952.
https:/…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/838031/psn-pdf
September 13, 2022 - Addressing the Loss of Trust in Safety Culture.
September 7, 2022
Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.
https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture
Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…
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psnet.ahrq.gov/node/73691/psn-pdf
September 08, 2021 - Pump up the volume: tips for increasing error reporting
and decreasing patient harm.
September 8, 2021
ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.
https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm
Error reporting is an essen…
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psnet.ahrq.gov/node/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
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psnet.ahrq.gov/node/47310/psn-pdf
September 19, 2018 - Use of simulation to test systems and prepare staff for a
new hospital transition.
September 19, 2018
Adler MD, Mobley BL, Eppich W, et al. Use of Simulation to Test Systems and Prepare Staff for a New
Hospital Transition. J Patient Saf. 2018;14(3):143-147. doi:10.1097/PTS.0000000000000184.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/42337/psn-pdf
December 30, 2014 - In situ simulation: detection of safety threats and
teamwork training in a high risk emergency department.
December 30, 2014
Patterson M, Geis GL, Falcone RA, et al. In situ simulation: detection of safety threats and teamwork
training in a high risk emergency department. BMJ Qual Saf. 2013;22(6):468-77. doi:10.113…
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psnet.ahrq.gov/node/40070/psn-pdf
December 08, 2010 - Epidural pump programming error leading to inadvertent
10-fold dosing error during epidural labor analgesia with
ropivacaine.
December 8, 2010
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-
Fold Dosing Error During Epidural Labor Analgesia With Ropivacaine. J Pat…
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psnet.ahrq.gov/node/45160/psn-pdf
May 18, 2016 - Clues to better health care from old malpractice lawsuits.
May 18, 2016
Landro L.
https://psnet.ahrq.gov/issue/clues-better-health-care-old-malpractice-lawsuits
Closed claims have been considered a source for adverse event data for years, and recently such data has
been utilized to inform safety improvement work. …
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psnet.ahrq.gov/node/47933/psn-pdf
August 07, 2019 - Just culture: it's more than policy.
August 7, 2019
Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45.
doi:10.1097/01.NUMA.0000558482.07815.ae.
https://psnet.ahrq.gov/issue/just-culture-its-more-policy
This survey study examined the relationship between just culture—a cultur…