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psnet.ahrq.gov/node/43429/psn-pdf
October 11, 2016 - CA sitting on millions in hospital fines.
October 11, 2016
Clark C.
https://psnet.ahrq.gov/issue/ca-sitting-millions-hospital-fines
Although California has collected an estimated $15 million in penalties from hospitals for adverse events,
this news piece describes how much of the money has yet to be allocated or s…
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psnet.ahrq.gov/node/36417/psn-pdf
April 12, 2011 - Excess mortality caused by medical injury.
April 12, 2011
Meurer LN, Yang H, Guse CE, et al. Excess mortality caused by medical injury. Ann Fam Med.
2006;4(5):410-6.
https://psnet.ahrq.gov/issue/excess-mortality-caused-medical-injury
The authors describe a state-based review of discharge diagnoses to identify medi…
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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - A bleeding risk index for estimating the probability of
major bleeding in hospitalized patient starting
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psnet.ahrq.gov/node/42378/psn-pdf
August 15, 2013 - Surgical adverse events: a systematic review.
August 15, 2013
Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg.
2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009.
https://psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review
This systematic review estimates…
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psnet.ahrq.gov/node/34919/psn-pdf
February 25, 2009 - Changes in prognosis after the first postoperative
complication.
February 25, 2009
Silber JH, Rosenbaum PR, Trudeau ME, et al. Changes in prognosis after the first postoperative
complication. Med Care. 2005;43(2):122-31.
https://psnet.ahrq.gov/issue/changes-prognosis-after-first-postoperative-complication
The aut…
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psnet.ahrq.gov/node/36401/psn-pdf
December 22, 2010 - Epidemiology of medication-related adverse events in
nursing homes.
December 22, 2010
Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing
homes. Am J Geriatr Pharmacother. 2006;4(3):264-72.
https://psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nu…
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psnet.ahrq.gov/node/43642/psn-pdf
November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report
Prepared for the Department of Health.
November 5, 2014
London, UK: Frontier Economics Ltd; October 2014.
https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health
This report provides an overview of evidence on preventabl…
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psnet.ahrq.gov/node/42648/psn-pdf
October 09, 2013 - The cost of poor blood specimen quality and errors in
preanalytical processes.
October 9, 2013
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem.
2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001.
https://psnet.ahrq.gov/issue/cost-poor-blood-specimen-q…
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psnet.ahrq.gov/node/47678/psn-pdf
December 19, 2018 - When mistakes happen.
December 19, 2018
Beck DL. ASH Clinical News. December 1, 2018.
https://psnet.ahrq.gov/issue/when-mistakes-happen
This article provides an overview of efforts to understand and improve patient safety and covers topics
such as the epidemiology of error, its impact on the individuals involved, …
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psnet.ahrq.gov/node/45047/psn-pdf
April 13, 2016 - Is misdiagnosis inevitable?
April 13, 2016
Page L. Medscape Business of Medicine. March 28, 2016.
https://psnet.ahrq.gov/issue/misdiagnosis-inevitable
This news article reports on the prevalence of diagnostic error and describes characteristics that contribute
to the problem, including insufficient clinician famil…
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psnet.ahrq.gov/node/41758/psn-pdf
October 10, 2012 - The Broselow tape as an effective medication dosing
instrument: a review of the literature.
October 10, 2012
Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review
of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.pedn.2012.04.009.
https://psnet.ah…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/node/47348/psn-pdf
September 05, 2018 - Hospital-Acquired Condition Reduction Program
(HACRP).
September 5, 2018
QualityNet. Centers for Medicare and Medicaid Services.
https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate
…
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psnet.ahrq.gov/node/40642/psn-pdf
July 27, 2011 - Prevalence of adverse drug events in ambulatory care: a
systematic review.
July 27, 2011
Taché S, Sönnichsen A, Ashcroft DM. Prevalence of adverse drug events in ambulatory care: a systematic
review. Ann Pharmacother. 2011;45(7-8):977-89. doi:10.1345/aph.1P627.
https://psnet.ahrq.gov/issue/prevalence-adverse-drug-…
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psnet.ahrq.gov/node/43215/psn-pdf
May 28, 2014 - When medical students make errors.
May 28, 2014
https://psnet.ahrq.gov/issue/when-medical-students-make-errors
This newspaper article highlights the need for medical students to be educated about how to disclose
errors to patients and families when mistakes occur, even if the patient was not harmed.
https://psnet.…
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psnet.ahrq.gov/node/40416/psn-pdf
June 27, 2018 - Reducing alarm hazards: selection and implementation of
alarm notification systems.
June 27, 2018
Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.
https://psnet.ahrq.gov/issue/reducing-alarm-hazards-selection-and-implementation-alarm-notification-
systems
Highlighting dangers presented by al…
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psnet.ahrq.gov/node/39991/psn-pdf
November 02, 2011 - Measuring the cost of hospital adverse patient safety
events.
November 2, 2011
Carey K, Stefos T. Measuring the cost of hospital adverse patient safety events. Health Econ.
2011;20(12):1417-30. doi:10.1002/hec.1680.
https://psnet.ahrq.gov/issue/measuring-cost-hospital-adverse-patient-safety-events
This analysis o…
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psnet.ahrq.gov/node/39783/psn-pdf
August 25, 2010 - Ethics, oversight and quality improvement initiatives.
August 25, 2010
Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and
Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034.
https://psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initia…
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psnet.ahrq.gov/node/37533/psn-pdf
April 22, 2011 - Systematic evaluation of errors occurring during the
preparation of intravenous medication.
April 22, 2011
Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of
intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743.
https://psnet.ahrq.gov/issue/sys…