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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Finally, recommendations
suggest that the nurse should vocalize both the name and the indication of
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - Finally, workarounds may ineffectively cover up dangerous system vulnerabilities.
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Finally, there was likely no urgent need to achieve a theophylline
blood level within the therapeutic
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psnet.ahrq.gov/node/42809/psn-pdf
January 01, 2015 - Patient Safety Measures.
December 11, 2013
Washington, DC: National Quality Forum.
https://psnet.ahrq.gov/issue/patient-safety-measures
This Web site tracks the progress of the development and review of measures to enhance reporting and
accountability of health care organizations in addressing risks to patient sa…
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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patient-safety-practices
July 27, 2018 - Book/Report
Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Citation Text:
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality; J…
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psnet.ahrq.gov/node/60615/psn-pdf
June 24, 2020 - Key potentially inappropriate drugs in pediatrics: the KIDs
list.
June 24, 2020
Meyers RS, Thackray J, Matson KL, et al. Key potentially inappropriate drugs in pediatrics: the KIDs list. J
Pediatr Pharmacol Ther. 2020;25(3). doi:10.5863/1551-6776-25.3.175.
https://psnet.ahrq.gov/issue/key-potentially-inappropriate…
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psnet.ahrq.gov/node/47641/psn-pdf
March 20, 2019 - Guided reflection interventions show no effect on
diagnostic accuracy in medical students.
March 20, 2019
Lambe KA, Hevey D, Kelly BD. Guided Reflection Interventions Show No Effect on Diagnostic Accuracy in
Medical Students. Front Psychol. 2018;9:2297. doi:10.3389/fpsyg.2018.02297.
https://psnet.ahrq.gov/issue/gu…
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psnet.ahrq.gov/node/74017/psn-pdf
October 27, 2021 - Ensuring primary care diagnostic quality in the era of
telemedicine.
October 27, 2021
Willis JS, Tyler C, Schiff GD, et al. Ensuring primary care diagnostic quality in the era of telemedicine. Am J
Med. 2021;134(9):1101-1103. doi:10.1016/j.amjmed.2021.04.027.
https://psnet.ahrq.gov/issue/ensuring-primary-care-diag…
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psnet.ahrq.gov/node/73958/psn-pdf
October 13, 2021 - Acting wisely in complex clinical situations: 'Mutual
safety' for clinicians as well as patients.
October 13, 2021
Dornan T, Lee C, Findlay-White F, et al. Acting wisely in complex clinical situations: ‘Mutual safety’ for
clinicians as well as patients. Med Teach. 2021;43(12):1419-1429. doi:10.1080/0142159x.2021.19…
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psnet.ahrq.gov/node/45262/psn-pdf
April 01, 2021 - Each Baby Counts.
April 1, 2021
Royal College of Obstetricians and Gynaecologists.
https://psnet.ahrq.gov/issue/each-baby-counts-key-messages-2015
This organization highlights the importance of in-depth reporting and investigation of adverse events in
labor and delivery, involving parents in the analysis, engaging…
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psnet.ahrq.gov/node/837506/psn-pdf
June 22, 2022 - Reducing pediatric emergency department prescription
errors.
June 22, 2022
Devarajan V, Nadeau NL, Creedon JK, et al. Reducing pediatric emergency department prescription errors.
Pediatrics. 2022;149(6):e2020014696. doi:10.1542/peds.2020-014696.
https://psnet.ahrq.gov/issue/reducing-pediatric-emergency-department-…
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psnet.ahrq.gov/node/40830/psn-pdf
October 05, 2011 - "Tech-check-tech": a review of the evidence on its safety
and benefits.
October 5, 2011
Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": a review of the evidence on its safety and benefits.
Am J Health Syst Pharm. 2011;68(19):1824-33. doi:10.2146/ajhp110022.
https://psnet.ahrq.gov/issue/tech-check-tech-review-ev…
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psnet.ahrq.gov/node/42344/psn-pdf
September 24, 2016 - Strategies for preventing distractions and interruptions in
the OR.
September 24, 2016
Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707.
doi:10.1016/j.aorn.2013.01.018.
https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or
Dist…
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psnet.ahrq.gov/node/46314/psn-pdf
November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use.
July 9, 2019
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient
Safety and Quality, and University of Chicago.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
Improving antibiotic use is a st…
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psnet.ahrq.gov/node/837501/psn-pdf
June 22, 2022 - Development and validation of a brief culture-of-safety
survey.
June 22, 2022
Barnard C, Chung JW, Flaherty V, et al. Development and validation of a brief culture-of-safety survey. Jt
Comm J Qual Patient Saf. 2022;48(9):430-438. doi:10.1016/j.jcjq.2022.04.006.
https://psnet.ahrq.gov/issue/development-and-validati…
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psnet.ahrq.gov/node/60943/psn-pdf
September 23, 2020 - Think twice: effects on diagnostic accuracy of returning
to the case to reflect upon the initial diagnosis.
September 23, 2020
Mamede S, Hautz WE, Berendonk C, et al. Think twice: effects on diagnostic accuracy of returning to the
case to reflect upon the initial diagnosis. Acad Med. 2020;95(8):1223-1229.
doi:10.1…
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psnet.ahrq.gov/node/838146/psn-pdf
September 21, 2022 - HSIB Maternity Investigation Programme Year in Review
2021/22. Summary of Highlights, Themes and Future
Work.
September 21, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; 2022.
https://psnet.ahrq.gov/issue/hsib-maternity-investigation-programme-year-review-202122-summary-
highlights-themes-and
Thi…
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psnet.ahrq.gov/node/39850/psn-pdf
January 19, 2011 - Tracing the foundations of a conceptual framework for a
patient safety ontology.
January 19, 2011
Runciman WB, Baker GR, Michel P, et al. Tracing the foundations of a conceptual framework for a patient
safety ontology. BMJ Qual Saf. 2010;19(6). doi:10.1136/qshc.2009.035147.
https://psnet.ahrq.gov/issue/tracing-fou…