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psnet.ahrq.gov/node/36242/psn-pdf
March 06, 2019 - Your attention please... designing effective warnings.
March 6, 2019
ISMP Medication Safety Alert! Acute care edition. February 28, 2019.
https://psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
Medication warnings inform providers and patients about risks associated with medication use. As w…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/844757/psn-pdf
September 11, 2019 - Diagnostic overshadowing in dentistry.
September 11, 2019
Clough S, Handley P. Diagnostic overshadowing in dentistry. Br Dent J. 2019;227(4):311-315.
doi:10.1038/s41415-019-0623-x.
https://psnet.ahrq.gov/issue/diagnostic-overshadowing-dentistry
Assumptions, communication barriers, and implicit biases can compromis…
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psnet.ahrq.gov/node/46461/psn-pdf
November 01, 2017 - Complications: acknowledging, managing, and coping
with human error.
November 1, 2017
Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl
Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28.
https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…
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psnet.ahrq.gov/node/42678/psn-pdf
February 21, 2015 - The reliability of AHRQ Common Format Harm Scales in
rating patient safety events.
February 21, 2015
Williams TL, Szekendi MK, Pavkovic S, et al. The reliability of AHRQ Common Format Harm Scales in
rating patient safety events. J Patient Saf. 2015;11(1):52-59. doi:10.1097/PTS.0b013e3182948ef9.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/41273/psn-pdf
June 01, 2012 - Minimizing inappropriate medications in older
populations: a ten-step conceptual framework.
June 1, 2012
Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step
conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1016/j.amjmed.2011.09.021.
https://psnet.ah…
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psnet.ahrq.gov/node/43882/psn-pdf
February 18, 2015 - Case Studies in Patient Safety: Foundations for Core
Competencies.
February 18, 2015
Johnson JK, Haskell HW, Barach PR. Burlington, MA: Jones and Bartlett Learning; 2015. ISBN:
9781449681548.
https://psnet.ahrq.gov/issue/case-studies-patient-safety-foundations-core-competencies
Patient stories can help illustrate…
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psnet.ahrq.gov/node/37846/psn-pdf
April 11, 2011 - Clinical profile of hospitalized children provided with
urgent assistance from a medical emergency team.
April 11, 2011
Kinney S, Tibballs J, Johnston L, et al. Clinical profile of hospitalized children provided with urgent
assistance from a medical emergency team. Pediatrics. 2008;121(6):e1577-e1584. doi:10.1542/p…
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psnet.ahrq.gov/node/43649/psn-pdf
November 05, 2014 - How patients can improve the accuracy of their medical
records.
November 5, 2014
Dullabh P, Sondheimer N, Katsh E, et al. How Patients Can Improve the Accuracy of their Medical
Records. eGEMs (Generating Evidence & Methods to improve patient outcomes). 2014;2(3).
doi:10.13063/2327-9214.1080.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46602/psn-pdf
February 21, 2018 - Are quality improvement collaboratives effective? A
systematic review.
February 21, 2018
Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ
Qual Saf. 2018;27(3):226-240. doi:10.1136/bmjqs-2017-006926.
https://psnet.ahrq.gov/issue/are-quality-improvement-coll…
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psnet.ahrq.gov/node/41420/psn-pdf
September 26, 2012 - Improving healthcare quality through organisational peer-
to-peer assessment: lessons from the nuclear power
industry.
September 26, 2012
Pronovost P, Hudson DW. Improving healthcare quality through organisational peer-to-peer assessment:
lessons from the nuclear power industry. BMJ Qual Saf. 2012;21(10):872-5.
h…
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psnet.ahrq.gov/node/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/46243/psn-pdf
June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and
Recovery.
June 5, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery
Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-
based S…
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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/node/46144/psn-pdf
June 28, 2017 - Reducing error in anticoagulant dosing via
multidisciplinary team rounding at point of care.
June 28, 2017
Sharma M, Krishnamurthy M, Snyder R, et al. Reducing error in anticoagulant dosing via multidisciplinary
team rounding at point of care. Clin Pract. 2017;7(2). doi:10.4081/cp.2017.953.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41810/psn-pdf
January 31, 2018 - Toolkit for Reduction of Clostridium difficile Infections
Through Antimicrobial Stewardship.
January 31, 2018
Boston University School of Public Health. Rockville, MD: Agency for Healthcare Research and Quality;
September 2012. AHRQ Publication No. 120082EF.
https://psnet.ahrq.gov/issue/toolkit-reduction-clostridi…
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psnet.ahrq.gov/node/60567/psn-pdf
June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the
Era of COVID-19.
June 3, 2020
National Academy of Medicine. April-June 2020.
https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
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psnet.ahrq.gov/node/47048/psn-pdf
April 22, 2023 - National Prescription Drug Take Back Day.
April 16, 2023
Drug Enforcement Administration. April 22, 2023.
https://psnet.ahrq.gov/issue/national-prescription-drug-take-back-day
Removing unused medications from the home can help prevent accidental exposure to unneeded
medications and limit their availability for mis…
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psnet.ahrq.gov/node/47540/psn-pdf
April 03, 2019 - Medication handling: towards a practical, human-centred
approach.
April 3, 2019
Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia.
2019;74(3):280-284. doi:10.1111/anae.14482.
https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…