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psnet.ahrq.gov/node/47369/psn-pdf
April 08, 2019 - Why do hundreds of US women die annually in
childbirth?
April 8, 2019
Slomski A. Why Do Hundreds of US Women Die Annually in Childbirth? JAMA. 2019;321(13):1239-1241.
doi:10.1001/jama.2019.0714.
https://psnet.ahrq.gov/issue/why-do-hundreds-us-women-die-annually-childbirth
Maternal mortality is a sentinel event th…
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psnet.ahrq.gov/node/852800/psn-pdf
August 23, 2023 - Handling injectable medications in anaesthesia:
Guidelines from the Association of Anaesthetists.
August 23, 2023
Kinsella SM, Boaden B, El?Ghazali S, et al. Handling injectable medications in anaesthesia: Guidelines
from the Association of Anaesthetists. Anaesthesia. 2023;78(10):1285-1294. doi:10.1111/anae.16095.
…
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psnet.ahrq.gov/node/43854/psn-pdf
February 11, 2015 - Medicare’s Oversight of Compounded Pharmaceuticals
Used in Hospitals.
February 11, 2015
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; January 2015. Report No. OEI-01-13-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-compounded-pharmaceuticals-use…
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www.ahrq.gov/funding/process/index.html
March 01, 2016 - Grants Process and Application Basics
Grant application process guidance and application basics.
Grant Application Basics
Provides links to guides on how to create grant applications to AHRQ to supporting research to improve the quality, effectiveness, accessibility, and cost effectiveness of health c…
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psnet.ahrq.gov/node/37403/psn-pdf
March 28, 2012 - Right medication, right dose, right patient, right time, and
right route: how do we select the right patient-controlled
analgesia (PCA) device?
March 28, 2012
Ladak SSJ, Chan VWS, Easty T, et al. Right medication, right dose, right patient, right time, and right route:
how do we select the right patient-controlled…
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psnet.ahrq.gov/node/44512/psn-pdf
September 23, 2015 - Increased mortality associated with weekend hospital
admission: a case for expanded seven day services?
September 23, 2015
Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekend hospital admission: a
case for expanded seven day services? BMJ. 2015;351:h4596. doi:10.1136/bmj.h4596.
https…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/47064/psn-pdf
August 22, 2018 - Lax oversight leaves surgery center regulators and
patients in the dark.
August 22, 2018
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
https://psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark
High-profile failures during office-based procedures have raised awareness o…
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psnet.ahrq.gov/node/837866/psn-pdf
August 17, 2022 - A System in Need of Repair: Addressing Organizational
Failures of the U.S.’s Organ Procurement and
Transplantation Network.
August 17, 2022
US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.
https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-
procurement…
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psnet.ahrq.gov/node/45912/psn-pdf
May 09, 2017 - Medication reconciliation failures in children and young
adults with chronic disease during intensive and
intermediate care.
May 9, 2017
DeCourcey DD, Silverman M, Chang E, et al. Medication reconciliation failures in children and young adults
with chronic disease during intensive and intermediate care. Pediatr Cr…
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psnet.ahrq.gov/node/844554/psn-pdf
February 15, 2023 - Medication mix-up: what happened at Vanderbilt and how
it impacts health care providers.
February 15, 2023
Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
https://psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-
providers
High-profile medication errors like tha…
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psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
May 07, 2018 - February 13, 2019
Ensuring competency and safety when onboarding newly hired professional
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psnet.ahrq.gov/issue/patient-safety-20
July 01, 2018 - Patient Safety in Office-Based Care Settings
January 31, 2024
Ensuring
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psnet.ahrq.gov/issue/standardize-4-safety
June 17, 2014 - December 15, 2021
Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital
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psnet.ahrq.gov/issue/compendium-2000-2005
September 06, 2011 - May 16, 2019
To Do No Harm: Ensuring Patient Safety in Health Care Organizations.
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psnet.ahrq.gov/issue/tips-topics-patient-safety
May 24, 2017 - January 17, 2012
Ensuring Correct Surgery.
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psnet.ahrq.gov/issue/doctors-say-im-sorry-see-you-court
February 24, 2010 - February 24, 2010
Ensuring medication reconciliation.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/wRAWvp7P8rdNS25gQLdAht
Clinicians should focus on ensuring that w omen receive adequate screening,
appropriate evaluation
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psnet.ahrq.gov/issue/quick-tips-when-planning-surgery
December 24, 2008 - May 1, 2016
Ensuring Correct Surgery.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-leadership.pptx
January 05, 2022 - Open lines of communication among team members, ensuring that they all can contribute their unique knowledge