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psnet.ahrq.gov/node/36418/psn-pdf
July 14, 2010 - Application of the IV Medication Harm Index to assess the
nature of harm averted by "smart" infusion safety
systems.
July 14, 2010
Williams CK, Maddox RR, Heape E, et al. Application of the IV Medication Harm Index to Assess the
Nature of Harm Averted by "Smart" Infusion Safety Systems. J Patient Saf. 2008;2(3).
…
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psnet.ahrq.gov/node/853061/psn-pdf
August 30, 2023 - Drug shortages.
August 30, 2023
Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. 2023;89(10):2950-2963.
https://psnet.ahrq.gov/issue/drug-shortages-0
Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing
definitions for drug shortages and the harms that can occu…
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psnet.ahrq.gov/node/42617/psn-pdf
January 24, 2018 - Improving Your Office Testing Process: A Step by Step
Guide for Rapid-Cycle Patient Safety and Quality
Improvement.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
https://psnet.ahrq.gov/issue/improving-your-office-testing-process-step-step-guide-rapid-cycle-patient-
safe…
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psnet.ahrq.gov/node/41018/psn-pdf
December 21, 2011 - What stands in the way of technology-mediated patient
safety improvements? A study of facilitators and barriers
to physicians' use of electronic health records.
December 21, 2011
Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of
facilitators and barriers to physician…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/36520/psn-pdf
June 14, 2011 - Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement
programme.
June 14, 2011
Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement programme. Qual Saf Health…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/environment-and-equipment/core-discussion.html
March 01, 2017 - Training Module 2 — Core Team Discussion Guide
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Clean Equipment and Environment: Knowledge and Practice
Directions
Answer the following questions to help reflect on how you can prepare to discuss cleaning and disinfection practices at your faci…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-graphic.pdf
February 01, 2019 - Action Planning for the SOPS™ Surveys Infographic
Action Planning for the
SOPSTM Surveys
January 2019 Webcast Highlights
AHRQ's Surveys on Patient Safety CultureTM(SOPS TM) Action
Planning Tool guides survey users seeking to improve
patient safety culture through the action planning process.
The Action Plann…
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psnet.ahrq.gov/node/44896/psn-pdf
March 23, 2016 - Computer-assisted diagnostic checklist in clinical
neurology.
March 23, 2016
Finelli PF, McCabe AL. Computer-assisted Diagnostic Checklist in Clinical Neurology. Neurologist.
2016;21(2):23-7. doi:10.1097/NRL.0000000000000071.
https://psnet.ahrq.gov/issue/computer-assisted-diagnostic-checklist-clinical-neurology
C…
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psnet.ahrq.gov/node/42324/psn-pdf
July 16, 2013 - Reducing risk in maternity by optimising teamwork and
leadership: an evidence-based approach to save mothers
and babies.
July 16, 2013
Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and
leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin …
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psnet.ahrq.gov/node/45133/psn-pdf
July 18, 2016 - Pharmacist medication reviews to improve safety
monitoring in primary care patients.
July 18, 2016
Gallimore CE, Sokhal D, Schreiter EZ, et al. Pharmacist medication reviews to improve safety monitoring in
primary care patients. Fam Syst Health. 2016;34(2):104-113. doi:10.1037/fsh0000185.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/43244/psn-pdf
June 18, 2014 - A retrospective review of crisis events in diagnostic
radiology: an analysis of frequency, demographics,
etiologies, and outcomes.
June 18, 2014
Tindel MS, Darby JM, Simmons RL. A retrospective review of crisis events in diagnostic radiology: an
analysis of frequency, demographics, etiologies, and outcomes. J Pati…
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psnet.ahrq.gov/node/46401/psn-pdf
September 13, 2017 - Understanding middle managers' influence in
implementing patient safety culture.
September 13, 2017
Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture.
BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4.
https://psnet.ahrq.gov/issue/understanding-mid…
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psnet.ahrq.gov/node/45011/psn-pdf
May 25, 2016 - High Reliability Organizations: A Healthcare Handbook for
Patient Safety & Quality.
May 25, 2016
Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940446387.
https://psnet.ahrq.gov/issue/high-reliability-organizations-healthcare-handbook-patient-safety-quality
This publicati…
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psnet.ahrq.gov/node/48099/psn-pdf
July 24, 2019 - Consumers' perspectives on their involvement in
recognizing and responding to patient
deterioration—developing a model for consumer
reporting.
July 24, 2019
King L, Peacock G, Crotty M, et al. Consumers' perspectives on their involvement in recognizing and
responding to patient deterioration-Developing a model fo…
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psnet.ahrq.gov/node/836784/psn-pdf
March 23, 2022 - Qualitative content analysis: a framework for the
substantive review of hospital incident reports.
March 23, 2022
Stephens S. Qualitative content analysis: a framework for the substantive review of hospital incident
reports. J Healthc Risk Manag. 2022;41(4):17-26. doi:10.1002/jhrm.21498.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47310/psn-pdf
September 19, 2018 - Use of simulation to test systems and prepare staff for a
new hospital transition.
September 19, 2018
Adler MD, Mobley BL, Eppich W, et al. Use of Simulation to Test Systems and Prepare Staff for a New
Hospital Transition. J Patient Saf. 2018;14(3):143-147. doi:10.1097/PTS.0000000000000184.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44087/psn-pdf
November 16, 2015 - Teaching a 'good' ward round.
November 16, 2015
Powell N, Bruce CG, Redfern O. Teaching a 'good' ward round. Clin Med (Lond). 2015;15(2):135-138.
doi:10.7861/clinmedicine.15-2-135.
https://psnet.ahrq.gov/issue/teaching-good-ward-round
Ward rounds, while an important educational activity, may not receive the attent…
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psnet.ahrq.gov/node/47695/psn-pdf
June 14, 2019 - No shortcuts to safer opioid prescribing.
June 14, 2019
Dowell D, Haegerich T, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med.
2019;380(24):2285-2287. doi:10.1056/NEJMp1904190.
https://psnet.ahrq.gov/issue/no-shortcuts-safer-opioid-prescribing
Improving opioid prescribing is a complex challenge tha…
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psnet.ahrq.gov/node/43133/psn-pdf
February 25, 2015 - The effectiveness of management-by-walking-around: a
randomized field study.
February 25, 2015
Tucker AL, Singer SJ. The Effectiveness of Management-By-Walking-Around: A Randomized Field Study.
Prod Oper Manag. 2014;24(2). doi:10.1111/poms.12226.
https://psnet.ahrq.gov/issue/effectiveness-management-walking-around…