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psnet.ahrq.gov/node/38644/psn-pdf
May 20, 2009 - A quality initiative to decrease pathology specimen-
labeling errors using radiofrequency identification in a
high-volume endoscopy center.
May 20, 2009
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling
errors using radiofrequency identification in a high-volume en…
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psnet.ahrq.gov/node/72786/psn-pdf
February 24, 2021 - Drug shortages amid the COVID-19 pandemic.
February 24, 2021
Bookwalter CM. US Pharmacist. 2021;46(2):25-28.
https://psnet.ahrq.gov/issue/drug-shortages-amid-covid-19-pandemic
COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of
supply-chain fact…
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psnet.ahrq.gov/node/845080/psn-pdf
February 22, 2023 - A high-reliability organization mindset.
February 22, 2023
Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual.
2022;37(6):504-510. doi:10.1097/jmq.0000000000000086.
https://psnet.ahrq.gov/issue/high-reliability-organization-mindset
The goal for health care organiz…
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psnet.ahrq.gov/node/38061/psn-pdf
November 08, 2008 - Medication errors in pediatric inpatients: prevalence and
results of a prevention program.
November 8, 2008
Otero P, Leyton A, Mariani G, et al. Medication errors in pediatric inpatients: prevalence and results of a
prevention program. Pediatrics. 2008;122(3):e737-43. doi:10.1542/peds.2008-0014.
https://psnet.ahrq…
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psnet.ahrq.gov/node/38803/psn-pdf
December 14, 2016 - Improving patient safety: effects of a safety program on
performance and culture in a department of radiology.
December 14, 2016
Donnelly LF, Dickerson JM, Goodfriend MA, et al. Improving patient safety: effects of a safety program on
performance and culture in a department of radiology. AJR Am J Roentgenol. 2009;1…
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psnet.ahrq.gov/node/43493/psn-pdf
February 18, 2015 - Hospital tones down alarms to reduce fatigue, enhance
safety.
February 18, 2015
Olson J.
https://psnet.ahrq.gov/issue/hospital-tones-down-alarms-reduce-fatigue-enhance-safety
Alarm fatigue has been recognized as a contributor to serious errors in hospitals. Reporting on how
nuisance alarms increase risks, this ne…
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psnet.ahrq.gov/node/44612/psn-pdf
October 28, 2015 - Transitional chaos or enduring harm? The EHR and the
disruption of medicine.
October 28, 2015
Rosenbaum L. Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine. New Engl
J Med. 2015;373(17):1585-1588. doi:10.1056/NEJMp1509961.
https://psnet.ahrq.gov/issue/transitional-chaos-or-enduring-harm-…
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psnet.ahrq.gov/node/39817/psn-pdf
March 18, 2011 - Checking it twice: an evaluation of checklists for
detecting medication errors at the bedside using a
chemotherapy model.
March 18, 2011
White RE, Trbovich PL, Easty AC, et al. Checking it twice: an evaluation of checklists for detecting
medication errors at the bedside using a chemotherapy model. Qual Saf Health …
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psnet.ahrq.gov/node/47142/psn-pdf
June 13, 2018 - Managing health IT risks: reflections and
recommendations.
June 13, 2018
Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform.
2018;25(1):952. doi:10.14236/jhi.v25i1.952.
https://psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations
Health information t…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/node/46272/psn-pdf
January 01, 2019 - Deployment of a second victim peer support program: a
replication study.
September 24, 2017
Merandi J, Liao NN, Lewe D, et al. Deployment of a second victim peer support program: a replication
study. Pediatr Qual Saf. 2019;2(4):e031. doi:10.1097/pq9.0000000000000031.
https://psnet.ahrq.gov/issue/deployment-second-…
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psnet.ahrq.gov/node/42727/psn-pdf
November 13, 2013 - Impact of electronic health record systems on information
integrity: quality and safety implications.
November 13, 2013
Bowman S. Impact of electronic health record systems on information integrity: quality and safety
implications. Perspect Health Inf Manag. 2013;10:1c.
https://psnet.ahrq.gov/issue/impact-electron…
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psnet.ahrq.gov/node/44339/psn-pdf
July 29, 2015 - Rapid response systems: a systematic review and meta-
analysis.
July 29, 2015
Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit
Care. 2015;19(1). doi:10.1186/s13054-015-0973-y.
https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis…
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psnet.ahrq.gov/node/38385/psn-pdf
February 04, 2009 - Impact of a computerized physician order entry system
on nurse-physician collaboration in the medication
process.
February 4, 2009
Pirnejad H, Niazkhani Z, van der Sijs H, et al. Impact of a computerized physician order entry system on
nurse-physician collaboration in the medication process. Int J Med Inform. 2008…
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psnet.ahrq.gov/node/40716/psn-pdf
March 22, 2017 - Promoting Safety and Quality Through Human Resource
Practices: Executive Summary.
March 22, 2017
McAlearney AS, Song P, Garman A, McHugh M, Caputo N. Rockville, MD: Agency for Healthcare
Research and Quality; August 2011. AHRQ Publication No. 11-0080-EF.
https://psnet.ahrq.gov/issue/promoting-safety-and-quality-th…
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psnet.ahrq.gov/node/838929/psn-pdf
October 26, 2022 - Toolkit To Improve Antibiotic Use in Ambulatory Care.
October 26, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit a…
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psnet.ahrq.gov/node/43018/psn-pdf
March 19, 2014 - Improved obstetric safety through programmatic
collaboration.
March 19, 2014
Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration.
J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131.
https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…
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psnet.ahrq.gov/node/35375/psn-pdf
January 02, 2017 - Integrating the intensive care unit safety reporting system
with existing incident reporting systems.
January 2, 2017
Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting
system with existing incident reporting systems. Jt Comm J Qual Patient Saf. 2005;31(10):585-93.…
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psnet.ahrq.gov/node/50734/psn-pdf
December 11, 2019 - The evolution of patient safety procedures in an oral
surgery department
December 11, 2019
Graham C, Reid S, Lord TC, et al. The evolution of patient safety procedures in an oral surgery
department. Br Dent J. 2019;226(1):32-38. doi:10.1038/sj.bdj.2019.5.
https://psnet.ahrq.gov/issue/evolution-patient-safety-proce…
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psnet.ahrq.gov/node/40980/psn-pdf
December 31, 2014 - Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies.
December 31, 2014
Grossman JM, Cross DA, Boukus ER, et al. Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19(3):353-9.
doi:1…