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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…
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psnet.ahrq.gov/node/43931/psn-pdf
March 04, 2015 - Design of endoscopic retrograde
cholangiopancreatography (ERCP) duodenoscopes may
impede effective cleaning.
March 4, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015.
https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp-
duode…
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psnet.ahrq.gov/node/836758/psn-pdf
March 16, 2022 - Internet of things in healthcare for patient safety: an
empirical study.
March 16, 2022
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study.
BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
https://psnet.ahrq.gov/issue/internet-things-healthc…
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psnet.ahrq.gov/node/846761/psn-pdf
September 29, 2018 - Using clinical simulation to study how to improve quality
and safety in healthcare.
September 29, 2018
Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in
healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47155/psn-pdf
October 17, 2018 - Medication errors with pediatric liquid acetaminophen
after standardization of concentration and packaging
improvements.
October 17, 2018
Brass EP, Reynolds KM, Burnham RI, et al. Medication Errors With Pediatric Liquid Acetaminophen After
Standardization of Concentration and Packaging Improvements. Acad Pediatr. …
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psnet.ahrq.gov/node/843325/psn-pdf
February 01, 2023 - Untenable expectations: nurses' work in the context of
medication administration, error, and the organization.
February 1, 2023
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration,
error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317.
doi:10.117…
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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/45520/psn-pdf
October 05, 2016 - Defining excellence: next steps for practicing clinicians
seeking to prevent diagnostic error.
October 5, 2016
Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic
error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994.
http…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - The critical incident technique.
March 5, 2008
FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358.
https://psnet.ahrq.gov/issue/critical-incident-technique
This review details the background of a methodology aimed to record specific behaviors, rather than
opinions or estimates, in evalu…
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psnet.ahrq.gov/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Before a drug is added to the formulary, the potential for look-alike or sound-alike error should be evaluated
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.