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psnet.ahrq.gov/issue/defining-and-enhancing-collaboration-between-community-pharmacists-and-primary-care-providers
July 07, 2021 - Review
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
Citation Text:
White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists and primary care providers to improve m…
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psnet.ahrq.gov/issue/evaluation-effectiveness-surgical-checklist-medicare-patients
January 13, 2016 - Study
Evaluation of the effectiveness of a surgical checklist in Medicare patients.
Citation Text:
Reames BN, Scally CP, Thumma JR, et al. Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients. Med Care. 2015;53(1):87-94. doi:10.1097/MLR.0000000000000277.
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psnet.ahrq.gov/issue/evaluation-and-mitigation-limitations-large-language-models-clinical-decision-making
March 09, 2022 - Commentary
Evaluation and mitigation of the limitations of large language models in clinical decision-making.
Citation Text:
Hager P, Jungmann F, Holland R, et al. Evaluation and mitigation of the limitations of large language models in clinical decision-making. Nat Med. 2024;30(9):2613-…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/impact-simulation-based-closed-loop-communication-training-medical-errors-pediatric-emergency
July 22, 2020 - Study
Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.
Citation Text:
Diaz MCG, Dawson K. Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department. Am J Med Qual…
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psnet.ahrq.gov/issue/identification-patient-information-corruption-intensive-care-unit-using-scoring-tool-direct
August 04, 2021 - Study
Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
Citation Text:
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit: using a scori…
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psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching-university
November 07, 2018 - Commentary
Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.
Citation Text:
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more…
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psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
August 08, 2018 - Study
Detecting unapproved abbreviations in the electronic medical record.
Citation Text:
Capraro A, Stack AM, Harper MB, et al. Detecting unapproved abbreviations in the electronic medical record. Jt Comm J Qual Patient Saf. 2012;38(4):178-183. doi:10.1016/s1553-7250(12)38023-9.
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - I” approach in which harm is thought to arise from linear, repeated processes that can be reliably improved
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/adverse-events-dentistry
Introduction
Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Medication/Drug Errors
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Share
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Created By: Dr. Yan Xiao, AHRQ TEP Member
Date…
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-
Based Patient Safety
January 31, 2024
Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/node/41626/psn-pdf
August 29, 2012 - Impact of resident participation in surgical operations on
postoperative outcomes: National Surgical Quality
Improvement Program.
August 29, 2012
Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on
Postoperative Outcomes. Ann Surg. 2012;256(3):469-475. doi:10.1097/sl…