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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35305/psn-pdf
    June 30, 2011 - Drug administration errors and their determinants in pediatric in-patients. June 30, 2011 Prot S, Fontan JE, Alberti C, et al. Drug administration errors and their determinants in pediatric in-patients. International Journal for Quality in Health Care. 2005;17(5). doi:10.1093/intqhc/mzi066. https://psnet.ahrq.gov/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45497/psn-pdf
    October 12, 2016 - Detection of adverse drug events using an electronic trigger tool. October 12, 2016 Lim D, Melucci J, Rizer MK, et al. Detection of adverse drug events using an electronic trigger tool. Am J Health Syst Pharm. 2016;73(17 Suppl 4):S112-20. doi:10.2146/ajhp150481. https://psnet.ahrq.gov/issue/detection-adverse-drug-…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35022/psn-pdf
    June 22, 2009 - The investigation and analysis of critical incidents and adverse events in healthcare. June 22, 2009 Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii. https://psnet.ahrq.gov/issue/in…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44551/psn-pdf
    September 30, 2015 - Safety culture includes "good catches." September 30, 2015 Traynor K. Safety culture includes "good catches". Am J Health Syst Pharm. 2015;72(19):1597-1599. doi:10.2146/news150065. https://psnet.ahrq.gov/issue/safety-culture-includes-good-catches Near misses can provide opportunities for learning if there is a pro…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43069/psn-pdf
    April 16, 2014 - Decimal numbers and safe interpretation of clinical pathology results. April 16, 2014 Sinnott M, Eley R, Steinle V, et al. Decimal numbers and safe interpretation of clinical pathology results. J Clin Pathol. 2014;67(2):179-81. doi:10.1136/jclinpath-2013-201865. https://psnet.ahrq.gov/issue/decimal-numbers-and-saf…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73256/psn-pdf
    May 12, 2021 - Addiction treatment providers in Pa. face little state scrutiny despite harm to clients. May 12, 2021 Pattani A, Mahon E. Kaiser Health News.  April 30, 2021. https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients Systemic oversight weaknesses and lack of…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74756/psn-pdf
    February 09, 2022 - Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022 Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005. https://psnet…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41084/psn-pdf
    January 25, 2012 - 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. January 25, 2012 Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2011;17(1). doi:10.1080/13548506.2011.592841. h…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41000/psn-pdf
    December 14, 2011 - Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. December 14, 2011 Patanwala AE, Hays DP, Sanders AB, et al. Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. Int J Pharm Pract. 2011;19(5):358-62. doi:10.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39251/psn-pdf
    September 24, 2016 - No interruptions please: impact of a no interruption zone on medication safety in intensive care units. September 24, 2016 Anthony K, Wiencek C, Bauer C, et al. No interruptions please: impact of a No Interruption Zone on medication safety in intensive care units. Crit Care Nurse. 2010;30(3):21-9. doi:10.4037/ccn20…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849130/psn-pdf
    May 17, 2023 - Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. May 17, 2023 Powell M. J Health Org Manag. 2023;37(1):67-83. https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry Individual, team, and organizational willingness to identify and add…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45391/psn-pdf
    August 10, 2016 - Where are my instruments? Hazards in delivery of surgical instruments. August 10, 2016 Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. https://psnet.ahrq.gov/issue/where-are-my-in…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41107/psn-pdf
    May 04, 2012 - A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. May 4, 2012 Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44775/psn-pdf
    June 07, 2016 - The effect of emergency department boarding on order completion. June 7, 2016 Coil CJ, Flood JD, Belyeu BM, et al. The Effect of Emergency Department Boarding on Order Completion. Ann Emerg Med. 2016;67(6):730-736.e2. doi:10.1016/j.annemergmed.2015.09.018. https://psnet.ahrq.gov/issue/effect-emergency-department-b…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851059/psn-pdf
    June 28, 2023 - Causes for medical errors in obstetrics and gynaecology. June 28, 2023 Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare (Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636. https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology R…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39333/psn-pdf
    May 04, 2010 - Explaining ethnic disparities in patient safety: a qualitative analysis. May 4, 2010 Suurmond J, Uiters E, de Bruijne M, et al. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health. 2010;100 Suppl 1:S113-7. doi:10.2105/AJPH.2009.167064. https://psnet.ahrq.gov/issue/explaining…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40960/psn-pdf
    November 30, 2011 - Creating an oversight infrastructure for electronic health record–related patient safety hazards. November 30, 2011 Singh H, Classen D, Sittig DF. Creating an oversight infrastructure for electronic health record-related patient safety hazards. J Patient Saf. 2011;7(4):169-74. doi:10.1097/PTS.0b013e31823d8df0. htt…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39108/psn-pdf
    November 18, 2009 - Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. November 18, 2009 Singh H, Daci K, Petersen L, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009;104(10):2543-2554. doi:10.1038/ajg.2009.324. https://psnet.a…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43211/psn-pdf
    July 16, 2015 - Seeking high reliability in primary care: leadership, tools, and organization. July 16, 2015 Weaver RR. Seeking high reliability in primary care: Leadership, tools, and organization. Health Care Manage Rev. 2015;40(3):183-92. doi:10.1097/HMR.0000000000000022. https://psnet.ahrq.gov/issue/seeking-high-reliability-p…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50625/psn-pdf
    November 06, 2019 - Pediatric medication safety considerations for pharmacists in an adult hospital setting. November 6, 2019 Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/ajhp/zxz168. https://psnet.ahrq.gov/is…

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