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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.
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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-…
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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.
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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…
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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…
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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…
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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.
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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…
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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.…
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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…
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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…
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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…
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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.…
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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…
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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…
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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…
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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…
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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…
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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…
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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…