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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/43224/psn-pdf
June 11, 2014 - Look alike/sound alike drugs: a literature review on
causes and solutions.
June 11, 2014
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J
Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
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psnet.ahrq.gov/node/37254/psn-pdf
January 02, 2017 - Creating a fair and just culture: one institution's path
toward organizational change.
January 2, 2017
Connor M, Duncombe D, Barclay E, et al. Creating a fair and just culture: one institution's pat toward
organizational change. Jt Comm J Qual Patient Saf. 2007;33(10):617-24.
https://psnet.ahrq.gov/issue/creating-…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - these
toolkits and auditing features to help elucidate how best to educate, implement change, and incorporate
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - That leads me almost directly into my next question, which is how the Essentials incorporate safety … I would be curious to hear you talk about how practice partners could engage academics and incorporate
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - That leads me almost directly into my next question, which is how the Essentials incorporate safety … I would be curious to hear you talk about how practice partners could engage academics and incorporate
-
psnet.ahrq.gov/node/47210/psn-pdf
November 16, 2018 - A multi-stakeholder consensus-driven research agenda
for better understanding and supporting the emotional
impact of harmful events on patients and families.
November 16, 2018
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for
Better Understanding and Supporting the …
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psnet.ahrq.gov/node/836843/psn-pdf
April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated
checklist for clinical decision support during PICU daily
rounds.
April 7, 2022
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist
for clinical decision support during PICU daily rounds. Pediatr Crit Care…
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psnet.ahrq.gov/issue/patient-safety-17
April 30, 2024 - Newsletter/Journal
Patient Safety.
Citation Text:
Patient Safety. Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
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Copy URL …
-
psnet.ahrq.gov/node/42945/psn-pdf
February 19, 2014 - Integrating patient safety into health professionals'
curricula: a qualitative study of medical, nursing and
pharmacy faculty perspectives.
February 19, 2014
Tregunno D, Ginsburg LR, Clarke B, et al. Integrating patient safety into health professionals' curricula: a
qualitative study of medical, nursing and pharma…
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Several reported PN-specific cases resulted
from failure to incorporate built-in dosing limits in the … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Institutions should incorporate
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - computerized provider
order entry systems with sophisticated clinical decision support systems that incorporate
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psnet.ahrq.gov/node/33725/psn-pdf
February 01, 2012 - Ideally, the development of milestones would incorporate mechanisms to objectively measure
competency
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - outcomes.[3]
Organizations throughout the healthcare sector are considering innovative approaches to incorporate
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psnet.ahrq.gov/issue/patient-safety-authority-annual-reports
December 09, 2020 - Book/Report
Patient Safety Authority Annual Reports.
Citation Text:
Patient Safety Authority Annual Reports. Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2024.
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psnet.ahrq.gov/issue/healthcare-411-patient-perspective
October 23, 2019 - Government Resource
Healthcare 411.
Citation Text:
Healthcare 411. Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
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psnet.ahrq.gov/issue/patient-safety-learning
January 12, 2022 - Multi-use Website
Patient Safety Learning.
Citation Text:
Patient Safety Learning. Patient Safety Learning.
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