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psnet.ahrq.gov/issue/hospitals-cultures-entrapment-re-analysis-bristol-royal-infirmary
May 21, 2019 - Commentary
Classic
Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.
Citation Text:
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. do…
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psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
May 13, 2009 - Commentary
Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.
Citation Text:
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…
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psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
December 04, 2013 - Study
A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions.
Citation Text:
Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…
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psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
June 23, 2015 - Study
Classic
Preventable anesthesia mishaps: a study of human factors.
Citation Text:
Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406.
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psnet.ahrq.gov/issue/overview-adverse-events-related-invasive-procedures-intensive-care-unit
November 29, 2023 - Study
Overview of adverse events related to invasive procedures in the intensive care unit.
Citation Text:
Pottier V, Daubin C, Lerolle N, et al. Overview of adverse events related to invasive procedures in the intensive care unit. Am J Infect Control. 2012;40(3):241-6. doi:10.1016/j.a…
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psnet.ahrq.gov/issue/chemotherapeutic-errors-hospitalised-cancer-patients-attributable-damage-and-extra-costs
May 04, 2012 - Study
Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs.
Citation Text:
Ranchon F, Salles G, Späth H-M, et al. Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. BMC Cancer. 2011;11:478. doi:10.1186/1…
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psnet.ahrq.gov/issue/human-factors-and-simulation-emergency-medicine
November 16, 2022 - Commentary
Human factors and simulation in emergency medicine.
Citation Text:
Hayden EM, Wong AH, Ackerman J, et al. Human Factors and Simulation in Emergency Medicine. Acad Emerg Med. 2018;25(2):221-229. doi:10.1111/acem.13315.
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psnet.ahrq.gov/issue/crisis-preparedness-systems-based-framework-avoiding-harm-surgery
September 14, 2022 - Study
Crisis preparedness: a systems-based framework for avoiding harm in surgery.
Citation Text:
Gogalniceanu P, Karydis N, Costan V-V, et al. Crisis preparedness: a systems-based framework for avoiding harm in surgery. J Am Coll Surg. 2022;235(4):612-623. doi:10.1097/xcs.00000000000003…
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psnet.ahrq.gov/issue/potential-medication-errors-associated-computer-prescriber-order-entry
May 05, 2014 - Study
Potential medication errors associated with computer prescriber order entry.
Citation Text:
Villamañán E, Larrubia Y, Ruano M, et al. Potential medication errors associated with computer prescriber order entry. Int J Clin Pharm. 2013;35(4):577-83. doi:10.1007/s11096-013-9771-2. …
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psnet.ahrq.gov/issue/medical-errors-orthopaedics-results-aaos-member-survey
August 04, 2021 - Study
Medical errors in orthopaedics. Results of an AAOS member survey.
Citation Text:
Wong DA, Herndon JH, Canale T, et al. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91(3):547-57. doi:10.2106/JBJS.G.01439.
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psnet.ahrq.gov/issue/incorporating-medication-indications-prescribing-process
May 01, 2019 - Commentary
Emerging Classic
Incorporating medication indications into the prescribing process.
Citation Text:
Kron K, Myers S, Volk LA, et al. Incorporating medication indications into the prescribing process. Am J Health-syst Pharm. 2018;75(11):774-783. doi:10.…
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psnet.ahrq.gov/issue/self-reported-violations-during-medication-administration-two-paediatric-hospitals
December 01, 2010 - Study
Self-reported violations during medication administration in two paediatric hospitals.
Citation Text:
Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two paediatric hospitals. BMJ Qual Saf. 2012;21(5):408-15. doi:10.1136/bmjqs-…
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psnet.ahrq.gov/issue/essential-activities-electronic-health-record-safety-qualitative-study
April 29, 2018 - Study
Essential activities for electronic health record safety: a qualitative study.
Citation Text:
Ash JS, Singh H, Wright A, et al. Essential activities for electronic health record safety: A qualitative study. Health Informatics J. 2019:1460458219833109. doi:10.1177/1460458219833109. …
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psnet.ahrq.gov/issue/safer-delivery-surgical-services-programme-controlled-and-after-intervention-studies-pre
October 12, 2016 - Book/Report
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis.
Citation Text:
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Poo…
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psnet.ahrq.gov/issue/ten-years-after-iom-report-engaging-residents-quality-and-patient-safety-creating-house-staff
December 27, 2014 - Commentary
Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.
Citation Text:
Fleischut PM, Evans AS, Nugent WC, et al. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a …
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psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
July 23, 2010 - Commentary
Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.
Citation Text:
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …
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psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized
October 19, 2022 - Commentary
Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry.
Citation Text:
Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…
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psnet.ahrq.gov/issue/commissioning-simulations-test-new-healthcare-facilities-proactive-and-innovative-approach
September 30, 2020 - Commentary
Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.
Citation Text:
Kaba A, Barnes S. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system …
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psnet.ahrq.gov/issue/diagnostic-reliability-teledermatology-systematic-review-and-meta-analysis
September 23, 2020 - Review
Diagnostic reliability in teledermatology: a systematic review and a meta-analysis.
Citation Text:
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-0…
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psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric
June 13, 2011 - Study
Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward.
Citation Text:
van Tilburg CM, Leistikow IP, Rademaker CMA, et al. Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology w…