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psnet.ahrq.gov/node/43607/psn-pdf
October 15, 2014 - Dallas Ebola case shows even sound plans can fail
spectacularly.
October 15, 2014
Loftis RL. Dallas Morning News. October 5, 2014.
https://psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. Th…
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psnet.ahrq.gov/node/36498/psn-pdf
January 07, 2011 - Recommendations from the British Committee for
Standards in Haematology and National Patient Safety
Agency.
January 7, 2011
Baglin TP, Cousins D, Keeling DM, et al. Safety indicators for inpatient and outpatient oral anticoagulant
care: [corrected] Recommendations from the British Committee for Standards in Haemat…
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psnet.ahrq.gov/node/35059/psn-pdf
June 22, 2009 - Adverse events associated with sedatives, analgesics,
and other drugs that provide patient comfort in the
intensive care unit.
June 22, 2009
Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide
patient comfort in the intensive care unit. Pharmacotherapy. 2005;25…
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psnet.ahrq.gov/node/37332/psn-pdf
November 14, 2007 - Is Our Pharmacy Meeting Patients' Needs? A Pharmacy
Health Literacy Assessment Tool User's Guide.
November 14, 2007
Jacobson KL, Gazmararian JA, Kripalani S, et al. Rockville, MD: Agency for Healthcare Research and
Quality. October 2007. AHRQ Publication No. 07-0051.
https://psnet.ahrq.gov/issue/our-pharmacy-meeti…
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psnet.ahrq.gov/node/34924/psn-pdf
February 27, 2009 - Medication errors in family practice, in hospitals and after
discharge from the hospital: an ethical analysis.
February 27, 2009
Clark PA. Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical
analysis. J Law Med Ethics. 2004;32(2):349-57, 192.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41583/psn-pdf
August 08, 2012 - Achieving the 'perfect handoff' in patient transfers:
building teamwork and trust.
August 8, 2012
Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building
teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-2834.2012.01400.x.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/38584/psn-pdf
June 17, 2014 - Taking the Lead in Patient Safety: How Healthcare
Leaders Influence Behavior and Create Culture.
June 17, 2014
Krause TR, Hidley J. Hoboken, NJ: Wiley; 2008. ISBN: 9780470225394.
https://psnet.ahrq.gov/issue/taking-lead-patient-safety-how-healthcare-leaders-influence-behavior-and-
create-culture
With insight from…
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psnet.ahrq.gov/node/46417/psn-pdf
October 11, 2017 - Center for Health Care Human Factors.
October 11, 2017
Armstrong Institute for Patient Safety and Quality.
https://psnet.ahrq.gov/issue/center-health-care-human-factors
Human factors engineering has provided unique insights into designing solutions to address human error
and system weaknesses that facilitate mista…
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psnet.ahrq.gov/node/45998/psn-pdf
April 19, 2017 - Learning and mindfulness: improving perioperative
patient safety.
April 19, 2017
Graling PR, Sanchez JA. Learning and mindfulness: improving perioperative patient safety. AORN J.
2017;105(3):317-321. doi:10.1016/j.aorn.2017.01.006.
https://psnet.ahrq.gov/issue/learning-and-mindfulness-improving-perioperative-patie…
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psnet.ahrq.gov/node/43734/psn-pdf
January 21, 2015 - Explicit and Standardized Prescription Medicine
Instructions.
January 21, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions
Standardization has been embraced as a strategy to improve health litera…
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psnet.ahrq.gov/node/37555/psn-pdf
February 14, 2018 - ACOG Committee Opinion #730: fatigue and patient
safety.
February 14, 2018
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2018;131(2):e78-
e81.
https://psnet.ahrq.gov/issue/acog-committee-opinion-730-fatigue-and-patient-safety
This commentary discusses how sleep deprivation affects…
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psnet.ahrq.gov/node/852463/psn-pdf
August 16, 2023 - Staying safe while getting well.
August 16, 2023
Salamon M. Harvard Women's Health Watch. August 1, 2023
https://psnet.ahrq.gov/issue/staying-safe-while-getting-well
Patients can help minimize the potential for adverse events while in the hospital. Actions such as working
with a care partner, tracking medications,…
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psnet.ahrq.gov/node/37518/psn-pdf
March 13, 2008 - Innovation in patient safety: a new task design in
reducing patient falls.
March 13, 2008
Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care
Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5.
https://psnet.ahrq.gov/issue/innovation-patient-safety…
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psnet.ahrq.gov/node/47435/psn-pdf
November 07, 2018 - Cognitive bias in clinical medicine.
November 7, 2018
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-
232. doi:10.4997/JRCPE.2018.306.
https://psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
Cognitive biases can lead to unnecessary treatment and de…
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psnet.ahrq.gov/node/42974/psn-pdf
September 07, 2016 - Chemotherapy drug shortages in pediatric oncology: a
consensus statement.
September 7, 2016
Decamp M, Joffe S, Fernandez C, et al. Chemotherapy drug shortages in pediatric oncology: a consensus
statement. Pediatrics. 2014;133(3):e716-24. doi:10.1542/peds.2013-2946.
https://psnet.ahrq.gov/issue/chemotherapy-drug-sh…
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psnet.ahrq.gov/node/35093/psn-pdf
June 22, 2009 - Epidemiology, comparative methods of detection, and
preventability of adverse drug events.
June 22, 2009
Al-Tajir GK, Kelly WN. Epidemiology, comparative methods of detection, and preventability of adverse drug
events. Ann Pharmacother. 2005;39(7-8):1169-74.
https://psnet.ahrq.gov/issue/epidemiology-comparative-me…
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psnet.ahrq.gov/node/45661/psn-pdf
November 09, 2016 - Center for Diagnostic Excellence.
November 9, 2016
Armstrong Institute for Patient Safety and Quality
https://psnet.ahrq.gov/issue/center-diagnostic-excellence
Diagnostic error has recently been recognized as a serious patient safety concern. Established within the
Armstrong Center for Patient Safety and Quality, …
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psnet.ahrq.gov/node/849139/psn-pdf
May 17, 2023 - How the opioid backlash went wrong.
May 17, 2023
Freedman DH. Newsweek Magazine. May 12, 2023.
https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong
The unintended consequences of reductions in access to prescription opioids can result in poor addiction
care and ineffective pain management. This articl…
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psnet.ahrq.gov/node/60236/psn-pdf
April 15, 2020 - Seattle pilot’s misdiagnosis highlights challenges around
coronavirus testing.
April 15, 2020
Malone P, Kamb L. Seattle Times. March 30, 2020.
https://psnet.ahrq.gov/issue/seattle-pilots-misdiagnosis-highlights-challenges-around-coronavirus-testing
False negative test results can contribute to misdiagnosis, treatm…
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psnet.ahrq.gov/node/46305/psn-pdf
September 27, 2017 - Using simulation to improve systems.
September 27, 2017
Kearney JA, Deutsch ES. Using Simulation to Improve Systems. Otolaryngol Clin North Am.
2017;50(5):1015-1028. doi:10.1016/j.otc.2017.05.011.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems-0
Simulations in health care can help uncover technical …