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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/33604/psn-pdf
December 15, 2024 - Pharmacist's Role in Medication Safety
December 15, 2024
The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/issue/ihi-announces-hospitals-participating-100000-lives-campaign-have-saved-estimated-122300-lives
August 07, 2024 - Press Release/Announcement
Classic
IHI announces that hospitals participating in 100,000 Lives Campaign have saved an estimated 122,300 lives.
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psnet.ahrq.gov/issue/what-correct-site-surgery
October 15, 2018 - Fact Sheet/FAQs
What is Correct-Site Surgery?
Citation Text:
What is Correct-Site Surgery? American College of Surgeons.
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psnet.ahrq.gov/node/43112/psn-pdf
July 03, 2016 - A systematic review of the effects of resident duty hour
restrictions in surgery: impact on resident wellness,
training, and patient outcomes.
July 3, 2016
Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in
surgery: impact on resident wellness, training, a…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/40944/psn-pdf
March 06, 2012 - Using the Agency for Healthcare Research and Quality
Patient Safety Indicators for targeting nursing quality
improvement.
March 6, 2012
Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient
safety indicators for targeting nursing quality improvement. J Nurs Care Qual. …
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psnet.ahrq.gov/node/40085/psn-pdf
December 15, 2010 - Medication reconciliation in the emergency department:
opportunities for workflow redesign.
December 15, 2010
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for
workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121.
https://psnet.ah…
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psnet.ahrq.gov/node/42456/psn-pdf
September 09, 2013 - A toolkit to disseminate best practices in inpatient
medication reconciliation: Multi-Center Medication
Reconciliation Quality Improvement Study (MARQUIS).
September 9, 2013
Mueller SK, Kripalani S, Stein J, et al. A toolkit to disseminate best practices in inpatient medication
reconciliation: multi-center medicat…
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psnet.ahrq.gov/node/43974/psn-pdf
April 26, 2015 - 2014 John M. Eisenberg Patient Safety and Quality Award
Recipients Announced.
April 26, 2015
Joint Commission.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
im…
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psnet.ahrq.gov/node/46586/psn-pdf
January 01, 2020 - Adverse event reporting: harnessing residents to improve
patient safety.
November 8, 2017
Tevis SE, Schmocker RK, Wetterneck TB. Adverse Event Reporting. J Patient Saf. 2020;16(4):294-298.
doi:10.1097/pts.0000000000000333.
https://psnet.ahrq.gov/issue/adverse-event-reporting-harnessing-residents-improve-patient-sa…
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psnet.ahrq.gov/node/44660/psn-pdf
December 02, 2015 - The SQUIRE Guidelines: an evaluation from the field, 5
years post release.
December 2, 2015
Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post
release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116.
https://psnet.ahrq.gov/issue/squire-guidel…
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psnet.ahrq.gov/node/838194/psn-pdf
September 28, 2022 - Measure Dx: implementing pathways to discover and
learn from diagnostic errors.
September 28, 2022
Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic
errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068.
https://psnet.ahrq.gov/issue/meas…
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psnet.ahrq.gov/node/36658/psn-pdf
May 27, 2011 - Potassium and phosphorus repletion in hospitalized
patients: implications for clinical practice and the
potential use of healthcare information technology to
improve prescribing and patient safety.
May 27, 2011
Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphorus repletion in hospitalized
patient…
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psnet.ahrq.gov/node/36520/psn-pdf
June 14, 2011 - Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement
programme.
June 14, 2011
Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement programme. Qual Saf Health…
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psnet.ahrq.gov/node/39920/psn-pdf
October 13, 2010 - Beliefs of ambulatory care physicians about accuracy of
patient medication records and technology-enhanced
solutions to improve accuracy.
October 13, 2010
Weeks DL, Corbett CF, Stream G. Beliefs of ambulatory care physicians about accuracy of patient
medication records and technology-enhanced solutions to improve …
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psnet.ahrq.gov/node/74048/psn-pdf
November 10, 2021 - Causes of use errors in ventilation devices--systematic
review.
November 10, 2021
Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl
Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544.
https://psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-s…
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psnet.ahrq.gov/node/47842/psn-pdf
April 10, 2019 - Learning From Invited Reviews.
April 10, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/learning-invited-reviews
Physical demands and technical complexities can affect surgical safety. This resource is designed to
capture frontline perceptions of surgeons in the United Ki…
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psnet.ahrq.gov/node/47827/psn-pdf
February 27, 2019 - Improving Usability, Safety and Patient Outcomes With
Health Information Technology.
February 27, 2019
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN:
9781614999508.
https://psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technol…