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psnet.ahrq.gov/node/39819/psn-pdf
April 04, 2011 - Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients.
April 4, 2011
Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-78. doi:10.111…
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psnet.ahrq.gov/node/46912/psn-pdf
March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services
Are Failing Patients.
March 28, 2018
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients
Patients with mental health conditions fac…
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psnet.ahrq.gov/node/843082/psn-pdf
January 25, 2023 - Determination of unnecessary blood transfusion by
comprehensive 15-hospital record review.
January 25, 2023
Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by
comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):42-52.
doi:10.1016/j.jcjq.2022.1…
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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/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/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/45212/psn-pdf
November 23, 2016 - The impact of implementation of family-initiated
escalation of care for the deteriorating patient in hospital:
a systematic review.
November 23, 2016
Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the
Deteriorating Patient in Hospital: A Systematic Review. …
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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/42264/psn-pdf
May 25, 2022 - Safety Considerations for Container Labels and Carton
Labeling Design to Minimize Medication Errors: Guidance
for Industry.
May 25, 2022
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; May 18, 2022.
https://psnet.ahrq.gov/issue/safe…
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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/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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www.ahrq.gov/patient-safety/settings/hospital/match/table-5.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 5: Identifying Challenges and Addressing Barriers
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Introducti…
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psnet.ahrq.gov/node/46760/psn-pdf
January 24, 2018 - Systematic evidence review of rates and burden of harm
of intravenous admixture drug preparation errors in
healthcare settings.
January 24, 2018
Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of
intravenous admixture drug preparation errors in healthcare settings. B…
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psnet.ahrq.gov/node/43625/psn-pdf
October 29, 2014 - Assessing distractors and teamwork during surgery:
developing an event-based method for direct observation.
October 29, 2014
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an
event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
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psnet.ahrq.gov/node/845657/psn-pdf
March 08, 2023 - Dissemination and Implementation of Equity-Focused
Evidence-Based Interventions in Healthcare Delivery
Systems (R18).
March 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality. February 15, 2023. RFA-HS-23-002.
https://psnet.ahrq.gov/issue/dissemination-and-implementation-equity-focused-evidence-base…
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psnet.ahrq.gov/node/851652/psn-pdf
July 26, 2023 - Breast cancer missed at screening; hindsight or
mistakes?
July 26, 2023
Hovda T, Larsen M, Romundstad L, et al. Breast cancer missed at screening; hindsight or mistakes? Eur J
Radiol. 2023;165:110913. doi:10.1016/j.ejrad.2023.110913.
https://psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes…
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psnet.ahrq.gov/node/72606/psn-pdf
December 23, 2020 - Best Practices in Developing Proprietary Names for
Human Prescription Drug Products Guidance for Industry.
December 23, 2020
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 2020.
https://psnet.ahrq.gov/issue/best-practices-d…
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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/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/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…