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psnet.ahrq.gov/node/39773/psn-pdf
August 18, 2010 - Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider
order entry warning system.
August 18, 2010
Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider order e…
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psnet.ahrq.gov/node/72708/psn-pdf
February 03, 2021 - How communication "failed" or "saved the day":
counterfactual accounts of medical errors.
February 3, 2021
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual
Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1177/2374373520925270.
https://p…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/837506/psn-pdf
June 22, 2022 - Reducing pediatric emergency department prescription
errors.
June 22, 2022
Devarajan V, Nadeau NL, Creedon JK, et al. Reducing pediatric emergency department prescription errors.
Pediatrics. 2022;149(6):e2020014696. doi:10.1542/peds.2020-014696.
https://psnet.ahrq.gov/issue/reducing-pediatric-emergency-department-…
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psnet.ahrq.gov/node/35216/psn-pdf
December 22, 2009 - An educational intervention to enhance nurse leaders'
perceptions of patient safety culture.
December 22, 2009
Ginsburg LR, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders'
perceptions of patient safety culture. Health Serv Res. 2005;40(4):997-1020.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/47355/psn-pdf
September 05, 2018 - Preventing medication errors in the information age.
September 5, 2018
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-
58. doi:10.1097/01.NURSE.0000544230.51598.38.
https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age
Failure to consider…
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psnet.ahrq.gov/node/45073/psn-pdf
May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
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psnet.ahrq.gov/node/866073/psn-pdf
June 05, 2024 - Improving communication of diagnostic uncertainty to
families of hospitalized children.
June 5, 2024
Young EE, Kane J, Timmons K, et al. Improving communication of diagnostic uncertainty to families of
hospitalized children. Diagnosis (Berl). 2024;11(2):186-191. doi:10.1515/dx-2023-0088.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/866809/psn-pdf
September 25, 2024 - Stop the line: interventions to prevent retained surgical
items.
September 25, 2024
Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81.
doi:10.1002/aorn.14190.
https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
Retained surgica…
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psnet.ahrq.gov/node/39270/psn-pdf
February 03, 2010 - Organization-wide adoption of computerized provider
order entry systems: a study based on diffusion of
innovations theory.
February 3, 2010
Rahimi B, Timpka T, Vimarlund V, et al. Organization-wide adoption of computerized provider order entry
systems: a study based on diffusion of innovations theory. BMC Med Info…
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psnet.ahrq.gov/node/43736/psn-pdf
April 24, 2017 - Seeing risk and allocating responsibility: talk of culture
and its consequences on the work of patient safety.
April 24, 2017
Szymczak JE. Seeing risk and allocating responsibility: talk of culture and its consequences on the work of
patient safety. Soc Sci Med. 2014;120:252-9. doi:10.1016/j.socscimed.2014.09.023.
…
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psnet.ahrq.gov/node/39707/psn-pdf
January 07, 2015 - Introduction of a rapid response system at a United
States Veterans Affairs hospital reduced cardiac arrests.
January 7, 2015
Lighthall GK, Parast L, Rapoport L, et al. Introduction of a rapid response system at a United States
veterans affairs hospital reduced cardiac arrests. Anesth Analg. 2010;111(3):679-86.
do…
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psnet.ahrq.gov/node/46755/psn-pdf
May 30, 2018 - Innovative approach to reconstruct bedside handoff:
using simple rules of complexity science to promote
partnership with patients.
May 30, 2018
Anthony MK, Kloos J, Beam P, et al. Innovative Approach to Reconstruct Bedside Handoff: Using Simple
Rules of Complexity Science to Promote Partnership With Patients. J Nu…
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psnet.ahrq.gov/node/46222/psn-pdf
June 21, 2017 - Enhanced time out: an improved communication process.
June 21, 2017
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570.
doi:10.1016/j.aorn.2017.03.014.
https://psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
The Universal Protocol requires hospitals t…
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psnet.ahrq.gov/node/42002/psn-pdf
May 10, 2013 - National efforts to improve health information system
safety in Canada, the United States of America and
England.
May 10, 2013
Kushniruk AW, Bates DW, Bainbridge M, et al. National efforts to improve health information system safety
in Canada, the United States of America and England. Int J Med Inform. 2013;82(5):…
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psnet.ahrq.gov/node/50453/psn-pdf
October 09, 2019 - Effect of a sedation weaning protocol on safety and
medication use among hospitalized children post critical
illness
October 9, 2019
Solodiuk JC, Greco CD, O'Donnell KA, et al. Effect of a Sedation Weaning Protocol on Safety and
Medication Use among Hospitalized Children Post Critical Illness. J Pediatr Nurs. 2019…
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psnet.ahrq.gov/node/73871/psn-pdf
September 22, 2021 - Making Health Care Safer in Ambulatory Care Settings
and Long-term Care Facilities (R18).
September 22, 2021
Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r…
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psnet.ahrq.gov/node/841785/psn-pdf
December 21, 2022 - Request for Information: Creating a National Healthcare
System Action Alliance to Advance Patient Safety.
December 21, 2022
Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.
https://psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance…
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psnet.ahrq.gov/node/44320/psn-pdf
October 28, 2015 - Interventions for reducing medication errors in children in
hospital.
October 28, 2015
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in
hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3.
https://psnet.ahrq.gov/issue/int…
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psnet.ahrq.gov/node/43937/psn-pdf
May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
May 5, 2018
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices
Benchmarks tracking a wide spectru…