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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 …
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psnet.ahrq.gov/node/35473/psn-pdf
April 06, 2011 - A web-based incident reporting system and
multidisciplinary collaborative projects for patient safety
in a Japanese hospital.
April 6, 2011
Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative
projects for patient safety in a Japanese hospital. Qual Saf Health C…
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psnet.ahrq.gov/node/44363/psn-pdf
May 05, 2018 - Selection of incorrect medication pump leads to
chemotherapy overdose.
May 5, 2018
ISMP Canada. August 26, 2015;15:1-4.
https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose
Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…
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psnet.ahrq.gov/node/45176/psn-pdf
July 20, 2016 - Sustaining Improvement.
July 20, 2016
Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement;
2016.
https://psnet.ahrq.gov/issue/sustaining-improvement
Numerous activities and programs have been launched to improve patient safety, but sustaining
improvements can be …
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psnet.ahrq.gov/node/45777/psn-pdf
January 11, 2017 - Disclosure of adverse events in pediatrics.
January 11, 2017
McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management;
Council on Quality Improvement and Patient Safety. Pediatrics. 2016;138(6);e20163215.
https://psnet.ahrq.gov/issue/disclosure-adverse-events-pediatrics
Op…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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www.ahrq.gov/nursing-home/resources/risk-assessment-management.html
April 01, 2022 - Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19: Data Template
Resource: Risk Assessment and Management of Exposure of Healthcare Workers in the Context of COVID-19: Data Template
This tool is intended for health care facilities that have either cared for or admit…
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psnet.ahrq.gov/node/35304/psn-pdf
July 14, 2009 - Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events.
July 14, 2009
DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events. Med Care. 2005;43(9 Suppl):III63-II…
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psnet.ahrq.gov/node/41598/psn-pdf
August 15, 2012 - Obstetrician/gynecologist hospitalists: can we improve
safety and outcomes for patients and hospitals and
improve lifestyle for physicians?
August 15, 2012
Olson R, Garite TJ, Fishman A, et al. Obstetrician/gynecologist hospitalists: can we improve safety and
outcomes for patients and hospitals and improve lifesty…
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psnet.ahrq.gov/node/838139/psn-pdf
September 21, 2022 - Error traps in acute pain management in children.
September 21, 2022
Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr
Anaesth. 2022;32(9):982-992. doi:10.1111/pan.14514.
https://psnet.ahrq.gov/issue/error-traps-acute-pain-management-children
Appropriate pediatric pain…
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psnet.ahrq.gov/node/866359/psn-pdf
June 01, 2022 - Diagnostic Safety Toolkit.
June 1, 2022
Diagnostic Safety Toolkit.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0
Effective communication is critical as patients shift from one level of care to another as their diagnosis
evolves. This toolkit is designed to help academic medical centers initiate conversa…
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psnet.ahrq.gov/node/867773/psn-pdf
February 01, 2024 - Central Line Insertion Care Team Checklist.
February 1, 2024
Agency for Healthcare Research and Quality. Central Line Insertion Care Team Checklist.
https://psnet.ahrq.gov/issue/central-line-insertion-care-team-checklist
Checklists are helpful in reducing omissions in standardized processes designed to support safe…
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psnet.ahrq.gov/node/44135/psn-pdf
November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the
NHS.
November 6, 2015
Francis R. London, UK: Department of Health; February 2015.
https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of
…
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www.ahrq.gov/evidencenow/projects/heart-health/research-results/results/webinars/health-it.html
March 01, 2021 - Health Information Technology to Improve Primary Care
June 22, 2016: Practical Solutions for Supporting Primary Care Quality Improvement With Health Information Technology
This EvidenceNOW Webinar focused on how health information technology (IT) can support quality improvement (QI) in primary care practices.…
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psnet.ahrq.gov/node/44565/psn-pdf
October 14, 2015 - How to use online clinician rating systems.
October 14, 2015
Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA.
2015;314(13):1418. doi:10.1001/jama.2015.11957.
https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems
Clinician rating sites may not always pr…