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psnet.ahrq.gov/node/852448/psn-pdf
January 01, 2024 - A realist synthesis of interprofessional patient safety
activities and healthcare student attitudes towards patient
safety.
August 16, 2023
Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and
healthcare student attitudes towards patient safety. J Interp…
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psnet.ahrq.gov/node/46934/psn-pdf
March 14, 2018 - Engaging the front line: tapping into hospital-wide quality
and safety initiatives.
March 14, 2018
Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality
and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:10.1053/j.jvca.2017.05.038.
https://psn…
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psnet.ahrq.gov/node/42536/psn-pdf
August 13, 2014 - Levels of reflective thinking and patient safety: an
investigation of the mechanisms that impact on student
learning in a single cohort over a 5 year curriculum.
August 13, 2014
Ambrose LJ, Ker J. Levels of reflective thinking and patient safety: an investigation of the mechanisms that
impact on student learning i…
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psnet.ahrq.gov/node/72470/psn-pdf
January 01, 2021 - Safe use of the EHR by medical scribes: a qualitative
study.
November 18, 2020
Ash JS, Corby S, Mohan V, et al. Safe use of the EHR by medical scribes: a qualitative study. J Amer Med
Inform Assoc. 2021;28(2):294-302. doi:10.1093/jamia/ocaa199.
https://psnet.ahrq.gov/issue/safe-use-ehr-medical-scribes-qualitative-…
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psnet.ahrq.gov/node/48035/psn-pdf
May 29, 2019 - Is the future of medical diagnosis in computer
algorithms?
May 29, 2019
Gruber K. Is the future of medical diagnosis in computer algorithms? Lancet Digit Health. 2019;1(1):e15-
e16. doi:10.1016/s2589-7500(19)30011-1.
https://psnet.ahrq.gov/issue/future-medical-diagnosis-computer-algorithms
Artificial intelligence…
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psnet.ahrq.gov/node/44791/psn-pdf
January 13, 2016 - FDA Drug Safety Communication: FDA cautions about
dosing errors when switching between different oral
formulations of antifungal Noxafil (posaconazole); label
changes approved.
January 13, 2016
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…
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psnet.ahrq.gov/node/46947/psn-pdf
March 21, 2018 - Leaving patients to their own devices? Smart technology,
safety and therapeutic relationships.
March 21, 2018
Ho A, Quick O. Leaving patients to their own devices? Smart technology, safety and therapeutic
relationships. BMC Med Ethics. 2018;19(1):18. doi:10.1186/s12910-018-0255-8.
https://psnet.ahrq.gov/issue/leav…
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psnet.ahrq.gov/node/46216/psn-pdf
July 12, 2017 - Physician satisfaction with transition from CPOE to
paper-based prescription.
July 12, 2017
Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based
prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007.
https://psnet.ahrq.gov/issue/phys…
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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/node/43142/psn-pdf
June 15, 2014 - Development and sustainability of an inpatient-to-
outpatient discharge handoff tool: a quality improvement
project.
June 15, 2014
Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge
handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf. 2014;40(5…
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psnet.ahrq.gov/node/867136/psn-pdf
November 13, 2024 - Detecting clinical medication errors with AI enabled
wearable cameras.
November 13, 2024
Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable
cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2.
https://psnet.ahrq.gov/issue/detecting-clinical-medication…
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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.
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