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psnet.ahrq.gov/node/40312/psn-pdf
June 10, 2018 - Oops, sorry, wrong patient! A patient verification process
is needed everywhere, not just at the bedside.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. March 10, 2011;16:1-4.
https://psnet.ahrq.gov/issue/oops-sorry-wrong-patient-patient-verification-process-needed-everywhere-not-
just-bedside
Th…
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psnet.ahrq.gov/node/42214/psn-pdf
April 17, 2013 - This isn't my information! The impact of accurate identity
management on patient safety.
April 17, 2013
Garcia R. This isn't my information! The impact of accurate identity management on patient safety. Health
management technology. 2013;34(3):10-1.
https://psnet.ahrq.gov/issue/isnt-my-information-impact-accurate-…
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psnet.ahrq.gov/node/41543/psn-pdf
January 18, 2013 - Research on nursing handoffs for medical and surgical
settings: an integrative review.
January 18, 2013
Staggers N, Blaz JW. Research on nursing handoffs for medical and surgical settings: an integrative
review. J Adv Nurs. 2013;69(2):247-62. doi:10.1111/j.1365-2648.2012.06087.x.
https://psnet.ahrq.gov/issue/resea…
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psnet.ahrq.gov/node/42145/psn-pdf
March 27, 2013 - Trends in adverse events over time: why are we not
improving?
March 27, 2013
Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf.
2013;22(4):273-7. doi:10.1136/bmjqs-2013-001935.
https://psnet.ahrq.gov/issue/trends-adverse-events-over-time-why-are-we-not-improving
Th…
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psnet.ahrq.gov/node/36383/psn-pdf
March 03, 2011 - Patterns of errors contributing to trauma mortality:
lessons learned from 2,594 deaths.
March 3, 2011
Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality.
Transactions of the .. Meeting of the American Surgical Association. 2006;124.
doi:10.1097/01.sla.0000234655.83517.5…
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psnet.ahrq.gov/node/36692/psn-pdf
January 18, 2011 - The objective medical emergency team activation criteria:
a case-control study.
January 18, 2011
Cretikos M, Chen J, Hillman K, et al. The objective medical emergency team activation criteria: a case-
control study. Resuscitation. 2007;73(1):62-72.
https://psnet.ahrq.gov/issue/objective-medical-emergency-team-acti…
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psnet.ahrq.gov/node/42501/psn-pdf
January 07, 2015 - Syndromic surveillance for health information system
failures: a feasibility study.
January 7, 2015
Ong M-S, Magrabi F, Coiera E. Syndromic surveillance for health information system failures: a feasibility
study. J Am Med Inform Assoc. 2013;20(3):506-12. doi:10.1136/amiajnl-2012-001144.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38358/psn-pdf
September 12, 2016 - Failure to rescue as a process measure to evaluate fetal
safety during labor.
September 12, 2016
Beaulieu MJ. Failure to rescue as a process measure to evaluate fetal safety during labor. MCN Am J
Matern Child Nurs. 2009;34(1):18-23. doi:10.1097/01.NMC.0000343861.64614.c9.
https://psnet.ahrq.gov/issue/failure-resc…
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psnet.ahrq.gov/node/42384/psn-pdf
December 18, 2013 - Pediatric emergency nurses self-reported medication
safety practices.
December 18, 2013
Mattei JL, Gillespie GL. Pediatric emergency nurses' self-reported medication safety practices. J Pediatr
Nurs. 2013;28(6):596-602. doi:10.1016/j.pedn.2013.03.005.
https://psnet.ahrq.gov/issue/pediatric-emergency-nurses-self-re…
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psnet.ahrq.gov/node/43564/psn-pdf
January 15, 2019 - Are hospitals in a med safety standard slump?
January 15, 2019
Wild D. Pharmacy Practice News. September 8, 2014.
https://psnet.ahrq.gov/issue/are-hospitals-med-safety-standard-slump
Highlighting how hospital compliance rates with Joint Commission medication–related standards have
remained mostly unchanged from 20…
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psnet.ahrq.gov/node/43089/psn-pdf
April 02, 2014 - Save a brain, make a checklist.
April 2, 2014
Hamblin J. The Atlantic. March 17, 2014.
https://psnet.ahrq.gov/issue/save-brain-make-checklist
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as
reduced complication rates, along with research that questioned…
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psnet.ahrq.gov/node/47490/psn-pdf
December 05, 2018 - Check your medical records for dangerous errors.
December 5, 2018
Graham J. Kaiser Health News. November 21, 2018.
https://psnet.ahrq.gov/issue/check-your-medical-records-dangerous-errors
Patients can identify errors in their medical records that health care providers may not recognize. This
news article highlight…
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psnet.ahrq.gov/node/39824/psn-pdf
December 06, 2010 - Team working in intensive care: current evidence and
future endeavors.
December 6, 2010
Richardson J, West MA, Cuthbertson BH. Team working in intensive care: current evidence and future
endeavors. Curr Opin Crit Care. 2010;16(6):643-8. doi:10.1097/MCC.0b013e32833e9731.
https://psnet.ahrq.gov/issue/team-working-in…
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psnet.ahrq.gov/node/36667/psn-pdf
April 14, 2011 - Effective healthcare teams require effective team
members: defining teamwork competencies.
April 14, 2011
Leggat SG. Effective healthcare teams require effective team members: defining teamwork competencies.
BMC Health Serv Res. 2007;7:17.
https://psnet.ahrq.gov/issue/effective-healthcare-teams-require-effective-t…
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psnet.ahrq.gov/node/42757/psn-pdf
November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector.
November 20, 2013
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
Following the implementation of a large clinical information communicati…
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psnet.ahrq.gov/node/50662/psn-pdf
November 13, 2019 - Deep Dive: Safe Ambulatory Care, Strategies for Patient
Safety & Risk Reduction.
November 13, 2019
Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/deep-dive-safe-ambulatory-care-strategies-patient-safety-risk-reduction
Outpatient safety is gaining traction as a focal point of analysis and …
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psnet.ahrq.gov/node/35701/psn-pdf
July 12, 2010 - Improving the accuracy of patient identification in the
medication-use process.
July 12, 2010
Trapskin PJ, White L, Armitstead JA. Improving the accuracy of patient identification in the medication-use
process. Am J Health Syst Pharm. 2006;63(3):218, 220-2.
https://psnet.ahrq.gov/issue/improving-accuracy-patient-i…
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psnet.ahrq.gov/node/41282/psn-pdf
April 11, 2012 - Analysis of risk factors for adverse drug events in
critically ill patients.
April 11, 2012
Kane-Gill SL, Kirisci L, Verrico MM, et al. Analysis of risk factors for adverse drug events in critically ill
patients*. Crit Care Med. 2012;40(3):823-8. doi:10.1097/CCM.0b013e318236f473.
https://psnet.ahrq.gov/issue/analy…
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psnet.ahrq.gov/node/36993/psn-pdf
September 15, 2011 - A transdisciplinary team acting on evidence through
analyses of moot malpractice cases.
September 15, 2011
Constantino RE. A transdisciplinary team acting on evidence through analyses of moot malpractice cases.
Dimens Crit Care Nurs. 2007;26(4):150-5.
https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evid…
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psnet.ahrq.gov/node/60883/psn-pdf
September 02, 2020 - When the misdiagnosis is child abuse.
September 2, 2020
Clifford S. When the misdiagnosis is child abuse. The Atlantic. 2020;August 20.
https://psnet.ahrq.gov/issue/when-misdiagnosis-child-abuse
Diagnostic decision-making is susceptible to cognitive biases and error in stressful situations. This feature
article il…