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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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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Conclusion
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Table of Contents
Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Introduction
The Theory of Distributed Cognition
Nurs…
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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/60842/psn-pdf
August 26, 2020 - Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge.
August 26, 2020
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge. Res Social Adm Pharm. 2020;17(4):677-684.
doi:10.1016/j.saphar…
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psnet.ahrq.gov/node/846164/psn-pdf
March 15, 2023 - Crowding in the Emergency Department: Challenges for
the Care of Children.
March 15, 2023
Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of
Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971.
https://psnet.ahrq.gov/issue/crowdin…
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psnet.ahrq.gov/node/73178/psn-pdf
April 28, 2021 - Risk perception on the labour ward: a mixed methods
study.
April 28, 2021
McCarthy C, Meaney S, Rochford M, et al. Risk perception on the labour ward: a mixed methods study. J
Patient Saf Risk Manag. 2021;26(2):56-63. doi:10.1177/25160435211002428.
https://psnet.ahrq.gov/issue/risk-perception-labour-ward-mixed-met…
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - An estimated 1.3 million fewer harms were
experienced by patients from 2010 to 2013 than would have
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - same resonance in the patient safety field and being discussed as much as some of the other kinds of harms
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms … In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Artificial Intelligence: System-Level Considerations
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Created By: Lorri Zipper…
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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www.ahrq.gov/hai/clabsi-tools/guide.html
January 01, 2020 - Guide: Purpose and Use of CLABSI Tools
Purpose of the Tools
These tools are designed to support your efforts to implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI) in your unit. When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the…
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cds.ahrq.gov/sites/default/files/cds/artifact/171/Occupational%20Factors%20which%20Impact%20Diabetes,%20%20A%20Final%20Knowledge%20Resource%20Report%20(2015).pdf
January 01, 2015 - Benefits and Harms
The benefits of this recommendation are the identification of workplace factors … As noted by reviewers, the harms to using the
recommendation are the possibility of causing uncertainty