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psnet.ahrq.gov/node/43257/psn-pdf
August 14, 2014 - Barriers and success factors to the implementation of a
multi-site prospective adverse event surveillance system.
August 14, 2014
Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site
prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
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psnet.ahrq.gov/node/44344/psn-pdf
July 22, 2015 - Making healthcare safer by understanding, designing and
buying better IT.
July 22, 2015
Thimbleby H, Lewis A, Williams J. Making healthcare safer by understanding, designing and buying better
IT. Clin Med (Lond). 2015;15(3):258-62. doi:10.7861/clinmedicine.15-3-258.
https://psnet.ahrq.gov/issue/making-healthcare-s…
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psnet.ahrq.gov/node/60005/psn-pdf
March 04, 2020 - What if?: Transforming Diagnostic Research by
Leveraging a Diagnostic Process Map to Engage Patients
in Learning from Errors.
March 4, 2020
Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A
Diagnostic Process Map To Engage Patients In Learning From Errors. Washin…
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psnet.ahrq.gov/node/46447/psn-pdf
September 27, 2017 - Creating highly reliable accountable care organizations.
September 27, 2017
Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev.
2016;73(6):660-672.
https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations
High reliability is a goal throughout …
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psnet.ahrq.gov/node/46172/psn-pdf
June 21, 2017 - Flying lessons for clinicians: developing system 2
practice.
June 21, 2017
Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air
Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003.
https://psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-p…
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psnet.ahrq.gov/node/60697/psn-pdf
July 15, 2020 - FDA alerts health care professionals to the temporary
absence of warning statement on the vial caps of two
neuromuscular blocking agents.
July 15, 2020
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.
https://psnet.ahrq.gov/issue/fda-alerts-health-care-professionals-temporar…
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psnet.ahrq.gov/node/44771/psn-pdf
January 06, 2016 - Could it be done safely? Pharmacists views on safety and
clinical outcomes from the introduction of an advanced
role for technicians.
January 6, 2016
Napier P, Norris P, Braund R. Could it be done safely? Pharmacists views on safety and clinical outcomes
from the introduction of an advanced role for technicians. R…
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psnet.ahrq.gov/node/844802/psn-pdf
September 18, 2019 - Using proactive risk assessment (HFMEA) to improve
patient safety and quality associated with intraocular lens
selection and implantation in cataract surgery.
September 18, 2019
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to
Improve Patient Safety and Quality Associ…
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psnet.ahrq.gov/node/45138/psn-pdf
May 25, 2016 - Improving Weekend Out Of Hours Surgical Handover
(WOOSH).
May 25, 2016
Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ
Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190.
https://psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh
…
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psnet.ahrq.gov/node/44663/psn-pdf
September 27, 2016 - Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services.
September 27, 2016
Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services. J Hosp Med. 2016;11(9):620-…
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psnet.ahrq.gov/node/43127/psn-pdf
April 23, 2014 - An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the
hospital setting.
April 23, 2014
Rousseau M-P, Beauchesne M-F, Naud A-S, et al. An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the hospital settin…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/849123/psn-pdf
May 17, 2023 - Maximizing student potential: lessons for pharmacy
programs from the patient safety movement.
May 17, 2023
Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the
patient safety movement. Explor Res Clin Soc Pharm. 2023;9:100216. doi:10.1016/j.rcsop.2022.100216.
htt…
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psnet.ahrq.gov/node/43162/psn-pdf
June 16, 2014 - The use of report cards and outcome measurements to
improve the safety of surgical care: the American College
of Surgeons National Surgical Quality Improvement
Program.
June 16, 2014
Maggard-Gibbons M. The use of report cards and outcome measurements to improve the safety of surgical
care: the American College of…
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psnet.ahrq.gov/node/45339/psn-pdf
August 10, 2016 - Hospital at night: an organizational design that provides
safer care at night.
August 10, 2016
Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care
at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/45961/psn-pdf
June 23, 2017 - Burden of hospitalizations related to adverse drug events
in the USA: a retrospective analysis from large inpatient
database.
June 23, 2017
Poudel DR, Acharya P, Ghimire S, et al. Burden of hospitalizations related to adverse drug events in the
USA: a retrospective analysis from large inpatient database. Pharmacoe…
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psnet.ahrq.gov/node/74116/psn-pdf
November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an
Optimal Clinical Learning Environment to Achieve Safe
and High-Quality Patient Care, 2021.
November 24, 2021
Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN:
9781945365416.
https://psnet.ahrq.gov/issue/ncicle-pathwa…
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psnet.ahrq.gov/node/47874/psn-pdf
April 10, 2019 - Evaluating the effect of data standardization and
validation on patient matching accuracy.
April 10, 2019
Grannis SJ, Xu H, Vest JR, et al. Evaluating the effect of data standardization and validation on patient
matching accuracy. J Am Med Inform Assoc. 2019;26(5):447-456. doi:10.1093/jamia/ocy191.
https://psnet.a…
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psnet.ahrq.gov/node/45499/psn-pdf
May 03, 2017 - Patient safety and interprofessional education: a report of
key issues from two interprofessional workshops.
May 3, 2017
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from
two interprofessional workshops. J Interprof Care. 2017;31(2):154-163.
doi:10.1080/13561…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…