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psnet.ahrq.gov/issue/risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies
December 02, 2020 - Study
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
Citation Text:
Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52(5):584-6…
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psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-reliability-outcomes
March 14, 2023 - Newspaper/Magazine Article
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
Citation Text:
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! …
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psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
February 24, 2016 - Newspaper/Magazine Article
Drug shortages continue to compromise patient care.
Citation Text:
Drug shortages continue to compromise patient care. ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
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psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
July 08, 2015 - Newspaper/Magazine Article
The absence of a drug–disease interaction alert leads to a child's death.
Citation Text:
The absence of a drug–disease interaction alert leads to a child's death. ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
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psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
November 18, 2020 - Newspaper/Magazine Article
Nowhere is safe: record number of patients contracted Covid in the hospital in January.
Citation Text:
Nowhere is safe: record number of patients contracted Covid in the hospital in January. Levy R, Vestal AJ. Politico. February 19, 2022.
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psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting
October 19, 2022 - Commentary
Quality and patient safety teams in the perioperative setting.
Citation Text:
Serino MF. Quality and Patient Safety Teams in the Perioperative Setting. AORN J. 2015;102(6):617-28. doi:10.1016/j.aorn.2015.10.006.
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psnet.ahrq.gov/issue/nurses-perceptions-multidisciplinary-team-work-acute-health-care
January 06, 2017 - Image/Poster
Nurses' perceptions of multidisciplinary team work in acute health-care.
Citation Text:
Atwal A, Caldwell K. Nurses' perceptions of multidisciplinary team work in acute health-care. Int J Nurs Pract. 2006;12(6):359-65.
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psnet.ahrq.gov/issue/scene-childrens-hospitals-and-clinics-minnesota
September 24, 2010 - Commentary
On the scene at Children's Hospitals and Clinics of Minnesota.
Citation Text:
Malone G, Akre M, Hauck M. On the scene at Children's Hospitals and Clinics of Minnesota. Nurs Adm Q. 2009;33(1):54-61. doi:10.1097/01.NAQ.0000343349.93537.08.
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psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program
July 22, 2020 - Special or Theme Issue
Heart Failure: The Decline of a Historic Transplant Program.
Citation Text:
Heart Failure: The Decline of a Historic Transplant Program. Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
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psnet.ahrq.gov/issue/medical-errors-kill-thousands-people-each-year-are-hospitals-getting-any-safer
June 17, 2020 - Newspaper/Magazine Article
Medical errors kill thousands of people each year. But are hospitals getting any safer?
Citation Text:
Medical errors kill thousands of people each year. But are hospitals getting any safer? Weintraub K. USA Today. May 3, 2023.
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psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame
October 28, 2020 - Commentary
The emotional fallout from the culture of blame and shame.
Citation Text:
Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691.
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psnet.ahrq.gov/issue/side-errors-neurosurgery
November 17, 2010 - Study
Side errors in neurosurgery.
Citation Text:
Mitchell P, Nicholson CL, Jenkins A. Side errors in neurosurgery. Acta Neurochir (Wien). 2006;148(12):1289-92; discussion 1292.
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psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology
May 03, 2017 - Review
Quality and safety in pediatric hematology/oncology.
Citation Text:
Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9. doi:10.1002/pbc.24946.
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psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
September 27, 2023 - Study
Eight-year experience with a neurosurgical checklist.
Citation Text:
Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8. doi:10.1177/1062860610363305.
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psnet.ahrq.gov/issue/preprinted-order-sets-safety-intervention-pediatric-sedation
April 16, 2010 - Study
Preprinted order sets as a safety intervention in pediatric sedation.
Citation Text:
Broussard M, Bass PF, Arnold CL, et al. Preprinted order sets as a safety intervention in pediatric sedation. J Pediatr. 2009;154(6):865-8. doi:10.1016/j.jpeds.2008.12.022.
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psnet.ahrq.gov/issue/patient-reports-undesirable-events-during-hospitalization
March 28, 2011 - Study
Patient reports of undesirable events during hospitalization.
Citation Text:
Agoritsas T, Bovier PA, Perneger T. Patient reports of undesirable events during hospitalization. J Gen Intern Med. 2005;20(10):922-8.
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psnet.ahrq.gov/issue/nontechnical-skills-pediatric-surgery-factors-influencing-operative-performance
June 12, 2008 - Commentary
Nontechnical skills in pediatric surgery: factors influencing operative performance.
Citation Text:
Youngson GG. Nontechnical skills in pediatric surgery: Factors influencing operative performance. J Pediatr Surg. 2016;51(2):226-30. doi:10.1016/j.jpedsurg.2015.10.062.
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psnet.ahrq.gov/issue/frequency-and-type-errors-and-near-errors-reported-critical-care-nurses
June 21, 2006 - Study
Frequency and type of errors and near errors reported by critical care nurses.
Citation Text:
Frequency and type of errors and near errors reported by critical care nurses. Balas MC; Scott LD; Rogers AE.
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…