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psnet.ahrq.gov/node/38606/psn-pdf
January 02, 2017 - Using an electronic prescribing system to ensure
accurate medication lists in a large multidisciplinary
medical group.
January 2, 2017
Stock R, Scott J, Gurtel S. Using an electronic prescribing system to ensure accurate medication lists in a
large multidisciplinary medical group. Jt Comm J Qual Patient Saf. 2009;…
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psnet.ahrq.gov/node/35660/psn-pdf
June 25, 2010 - Increased catheter-related bloodstream infection rates
after the introduction of a new mechanical valve
intravenous access port.
June 25, 2010
Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after the
introduction of a new mechanical valve intravenous access port. In…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/node/43100/psn-pdf
April 02, 2014 - Taking National Action to Prevent and Eliminate
Healthcare-Associated Infections.
April 2, 2014
Kahn KL, Battles JB, eds. Med Care. 2014;52:i-ii,s1-s100.
https://psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
This special issue explores a national initiativ…
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psnet.ahrq.gov/node/41081/psn-pdf
February 01, 2012 - Workarounds in the use of IS in healthcare: a case study
of an electronic medication administration system.
February 1, 2012
Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an
electronic medication administration system. International Journal of Human-Computer Studi…
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psnet.ahrq.gov/node/35913/psn-pdf
February 16, 2011 - Improving oversight of the graduate medical education
enterprise: one institution's strategies and tools.
February 16, 2011
Afrin LB, Arana GW, Medio FJ, et al. Improving Oversight of the Graduate Medical Education Enterprise:
One Institution???s Strategies and Tools. Academic Medicine. 2006;81(5).
doi:10.1097/01.…
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Major software enhancements
Implementing computerized physician order entry for lab testing.
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - Leaders at institutions considering implementing remote telemetry monitoring must incorporate
perspectives
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - They also serve as a valuable rallying point to create a culture of safety on
maternity units by implementing
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/44053/psn-pdf
November 16, 2015 - ANA CAUTI Prevention Tool.
November 16, 2015
Silver Spring, MD: American Nurses Association; 2015.
https://psnet.ahrq.gov/issue/ana-cauti-prevention-tool
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This
toolkit, developed as a Partnership for Patients strategy, …
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psnet.ahrq.gov/node/34701/psn-pdf
January 04, 2017 - Making the business case for patient safety.
January 4, 2017
Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4,
1.
https://psnet.ahrq.gov/issue/making-business-case-patient-safety
While the costs of medical error to patients are well appreciated, the direct costs…
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psnet.ahrq.gov/node/41969/psn-pdf
July 02, 2014 - The creation and impact of a dedicated section on quality
and patient safety in a clinical academic department.
July 2, 2014
Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety
in a Clinical Academic Department. Academic Medicine. 2012;88(2). doi:10.1097/acm.0b013e3…
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psnet.ahrq.gov/node/46767/psn-pdf
January 17, 2018 - What this computer needs is a physician: humanism and
artificial intelligence.
January 17, 2018
Verghese A, Shah NH, Harrington RA. What This Computer Needs Is a Physician: Humanism and Artificial
Intelligence. JAMA. 2018;319(1):19-20. doi:10.1001/jama.2017.19198.
https://psnet.ahrq.gov/issue/what-computer-needs-p…
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psnet.ahrq.gov/node/45003/psn-pdf
July 18, 2016 - Effect of surgical safety checklists on pediatric surgical
complications in Ontario.
July 18, 2016
O'Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical
complications in Ontario. CMAJ. 2016;188(9):E191-E198. doi:10.1503/cmaj.151333.
https://psnet.ahrq.gov/issue/effect…
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psnet.ahrq.gov/node/43569/psn-pdf
April 25, 2016 - The safe day call: reducing silos in health care through
frontline risk assessment.
April 25, 2016
Paterson C, Miller K, Benden M, et al. The Safe Day Call: Reducing Silos in Health Care Through Frontline
Risk Assessment. Jt Comm J Qual Patient Saf. 2014;40(10):476-481.
https://psnet.ahrq.gov/issue/safe-day-call-r…
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psnet.ahrq.gov/node/42955/psn-pdf
May 11, 2016 - National Patient Safety Alerting System.
May 11, 2016
National Health Service England
https://psnet.ahrq.gov/issue/national-patient-safety-alerting-system
In response to the Francis report, this three-stage reporting system was launched to help National Health
Service organizations learn from incidents and incorpo…