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psnet.ahrq.gov/node/47456/psn-pdf
April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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psnet.ahrq.gov/node/857459/psn-pdf
December 06, 2023 - Five strategies for a safer EHR modernization journey.
December 6, 2023
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med.
2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
https://psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
Large-sca…
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psnet.ahrq.gov/node/46836/psn-pdf
February 21, 2018 - Drone delivery of medications: review of the landscape
and legal considerations.
February 21, 2018
Lin CA, Shah K, Mauntel LCC, et al. Drone delivery of medications: Review of the landscape and legal
considerations. Am J Health Syst Pharm. 2018;75(3):153-158. doi:10.2146/ajhp170196.
https://psnet.ahrq.gov/issue/dr…
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psnet.ahrq.gov/node/60625/psn-pdf
June 24, 2020 - Medical bias: from pain pills to COVID-19, racial
discrimination in health care festers.
June 24, 2020
O'Donnell J, Alltucker K. Medical bias: from pain pills to COVID-19, racial discrimination in health care
festers. USA Today. 2020;Jun 14.
https://psnet.ahrq.gov/issue/medical-bias-pain-pills-covid-19-racial-disc…
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psnet.ahrq.gov/node/48045/psn-pdf
June 05, 2019 - Obstetric practice guidelines: labor's love lost?
June 5, 2019
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med.
2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
Guidelines play a…
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psnet.ahrq.gov/node/45234/psn-pdf
November 18, 2016 - Recommended responsibilities for management of MR
safety.
November 18, 2016
Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J
Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282.
https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
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psnet.ahrq.gov/node/45382/psn-pdf
January 23, 2017 - The impact of major intraoperative adverse events on
hospital readmissions.
January 23, 2017
Nandan AR, Bohnen JD, Chang DC, et al. The impact of major intraoperative adverse events on hospital
readmissions. Am J Surg. 2017;213(1):10-17. doi:10.1016/j.amjsurg.2016.03.018.
https://psnet.ahrq.gov/issue/impact-major-…
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psnet.ahrq.gov/node/48188/psn-pdf
August 14, 2019 - Analysis of human performance deficiencies associated
with surgical adverse events.
August 14, 2019
Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With
Surgical Adverse Events. JAMA Netw Open. 2019;2(7):e198067.
doi:10.1001/jamanetworkopen.2019.8067.
https://psnet.ahr…
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psnet.ahrq.gov/node/43164/psn-pdf
May 03, 2016 - Patient safety in the era of healthcare reform.
May 3, 2016
Leape L. Patient safety in the era of healthcare reform. Clin Orthop Relat Res. 2015;473(5):1568-73.
doi:10.1007/s11999-014-3598-6.
https://psnet.ahrq.gov/issue/patient-safety-era-healthcare-reform
The publication of To Err Is Human spurred efforts to imp…
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psnet.ahrq.gov/node/41239/psn-pdf
March 21, 2012 - Emotional impact of patient safety incidents on family
physicians and their office staff.
March 21, 2012
O'Beirne M, Sterling P, Palacios-Derflingher L, et al. Emotional impact of patient safety incidents on family
physicians and their office staff. J Am Board Fam Med. 2012;25(2):177-83.
doi:10.3122/jabfm.2012.02.…
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psnet.ahrq.gov/node/48175/psn-pdf
August 07, 2019 - Strengthening the medical error "meme pool."
August 7, 2019
Mazer BL, Nabhan C. Strengthening the Medical Error "Meme Pool". J Gen Intern Med. 2019;34(10):2264-
2267. doi:10.1007/s11606-019-05156-7.
https://psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool
Published estimates on the number preventable med…
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - Alarm fatigue: impacts on patient safety.
December 16, 2015
Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol.
2015;28(6):685-690. doi:10.1097/ACO.0000000000000260.
https://psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety
Alarm fatigue is a recognized safety conce…
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psnet.ahrq.gov/node/44046/psn-pdf
August 21, 2015 - Development of an instrument to measure the unintended
consequences of EHRs.
August 21, 2015
Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended
Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083.
https://psnet.ahrq.gov/issue/devel…
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psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors.
July 23, 2014
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs
Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
Thi…
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psnet.ahrq.gov/node/46352/psn-pdf
October 15, 2018 - Optimal Resources for Surgical Quality and Safety.
October 15, 2018
Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
https://psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety
Surgery is complex and involves a wide range of possibilities for error that can r…
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psnet.ahrq.gov/node/846763/psn-pdf
March 29, 2023 - Why hospitals still make serious medical errors—and how
they are trying to reduce them.
March 29, 2023
Landro L. Wall Street Journal. March 12, 2023.
https://psnet.ahrq.gov/issue/why-hospitals-still-make-serious-medical-errors-and-how-they-are-trying-
reduce-them
Patient harm from health care is persistent d…
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psnet.ahrq.gov/node/73535/psn-pdf
July 28, 2021 - Wrong-patient orders in obstetrics.
July 28, 2021
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-patient orders in obstetrics. Obstet
Gynecol. 2021;138(2):229-235. doi:10.1097/aog.0000000000004474.
https://psnet.ahrq.gov/issue/wrong-patient-orders-obstetrics
Patient misidentification errors can re…
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psnet.ahrq.gov/node/43459/psn-pdf
August 27, 2014 - Serious Reportable Events.
August 27, 2014
Nova Scotia Department of Health and Wellness.
https://psnet.ahrq.gov/issue/serious-reportable-events
Incident reporting systems are an important method for capturing, analyzing, and learning about a broad
range of potential safety issues. This Web site provides access to…
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psnet.ahrq.gov/node/846460/psn-pdf
March 22, 2023 - I’m an ER doctor: here’s what I found when I asked
ChatGPT to diagnose my patients.
March 22, 2023
Tamayo-Sarver J. Fast Company. March 13, 2023.
https://psnet.ahrq.gov/issue/im-er-doctor-heres-what-i-found-when-i-asked-chatgpt-diagnose-my-patients
Artificial intelligence (AI) harbors risks and biases that can mis…
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psnet.ahrq.gov/node/45272/psn-pdf
October 12, 2016 - Recognising and responding to 'cutting corners' when
providing nursing care: a qualitative study.
October 12, 2016
Jones A, Johnstone M-J, Duke M. Recognising and responding to 'cutting corners' when providing nursing
care: a qualitative study. J Clin Nurs. 2016;25(15-16):2126-33. doi:10.1111/jocn.13352.
https://p…