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psnet.ahrq.gov/node/37787/psn-pdf
May 28, 2008 - Adoption of health information technology for medication
safety in US hospitals, 2006.
May 28, 2008
Furukawa MF, Raghu TS, Spaulding TJ, et al. Adoption of health information technology for medication
safety in U.S. Hospitals, 2006. Health Aff (Millwood). 2008;27(3):865-75. doi:10.1377/hlthaff.27.3.865.
https://ps…
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psnet.ahrq.gov/node/836964/psn-pdf
April 20, 2022 - Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a
cohort study using trigger tool methodology.
April 20, 2022
Nowak B, Schwendimann R, Lyrer P, et al. Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a …
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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psnet.ahrq.gov/node/36208/psn-pdf
January 05, 2017 - Implementing computerized provider order entry with an
existing clinical information system.
January 5, 2017
Barron WM, Reed L, Forsythe S, et al. Implementing computerized provider order entry with an existing
clinical information system. Jt Comm J Qual Patient Saf. 2006;32(9):506-16.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/39670/psn-pdf
July 07, 2010 - The Power of Safety: State Reporting Provides Lessons in
Reducing Harm, Improving Care.
July 7, 2010
Washington DC: National Quality Forum; 2010.
https://psnet.ahrq.gov/issue/power-safety-state-reporting-provides-lessons-reducing-harm-improving-care
The landmark Institute of Medicine (IOM) report, To Err Is Human,…
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psnet.ahrq.gov/node/46416/psn-pdf
March 13, 2018 - Opioid prescribing for opioid-naive patients in emergency
departments and other settings: characteristics of
prescriptions and association with long-term use.
March 13, 2018
Jeffery MM, Hooten M, Hess EP, et al. Opioid Prescribing for Opioid-Naive Patients in Emergency
Departments and Other Settings: Characteristi…
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psnet.ahrq.gov/node/849319/psn-pdf
May 24, 2023 - Attitudes of clinicians and patient safety culture before
and after the ARRIVE trial.
May 24, 2023
White VanGompel E, Carlock F, Singh L, et al. Attitudes of clinicians and patient safety culture before and
after the ARRIVE trial. J Obstet Gynecol Neonatal Nurs. 2023;52(3):211-222.
doi:10.1016/j.jogn.2022.12.007.
…
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psnet.ahrq.gov/node/35927/psn-pdf
February 17, 2011 - Claims, errors, and compensation payments in medical
malpractice litigation.
February 17, 2011
Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical
malpractice litigation. N Engl J Med. 2006;354(19):2024-33.
https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payme…
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psnet.ahrq.gov/node/37386/psn-pdf
January 06, 2017 - Medication reconciliation in ambulatory oncology.
January 6, 2017
Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual
Patient Saf. 2007;33(12):750-7.
https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology
The Joint Commission mandates systems…
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psnet.ahrq.gov/node/44646/psn-pdf
November 11, 2015 - The hidden costs of reconciling surgical sponge counts.
November 11, 2015
Steelman VM, Schaapveld AG, Perkhounkova Y, et al. The Hidden Costs of Reconciling Surgical Sponge
Counts. AORN J. 2015;102(5):498-506. doi:10.1016/j.aorn.2015.09.002.
https://psnet.ahrq.gov/issue/hidden-costs-reconciling-surgical-sponge-coun…
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psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - National Action Plan for Adverse Drug Event Prevention.
October 21, 2016
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health
and Human Services; September 2014.
https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
This national action pla…
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psnet.ahrq.gov/node/45473/psn-pdf
April 24, 2018 - Navigating a ship with a broken compass: evaluating
standard algorithms to measure patient safety.
April 24, 2018
Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard
algorithms to measure patient safety. J Am Med Inform Assoc. 2017;24(2):310-315.
doi:10.1093/jami…
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psnet.ahrq.gov/node/35737/psn-pdf
July 15, 2010 - Shepherding change: how the market, healthcare
providers, and public policy can deliver quality care for
the 21st century.
July 15, 2010
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy
can deliver quality care for the 21st century. Crit Care Med. 2006;34(3 Suppl)…
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psnet.ahrq.gov/node/34763/psn-pdf
March 07, 2005 - The Limits of Safety: Organizations, Accidents and
Nuclear Weapons.
March 7, 2005
Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
https://psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
Two competing paradigms dominate the study of the hazards associate…
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psnet.ahrq.gov/node/47930/psn-pdf
May 01, 2019 - Evolving quality improvement support strategies to
improve Plan–Do–Study–Act cycle fidelity: a retrospective
mixed-methods study.
May 1, 2019
McNicholas C, Lennox L, Woodcock T, et al. Evolving quality improvement support strategies to improve
Plan-Do-Study-Act cycle fidelity: a retrospective mixed-methods study. …
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psnet.ahrq.gov/node/73364/psn-pdf
January 01, 2022 - Impact of opioid administration in the intensive care unit
and subsequent use in opioid-naïve patients.
June 9, 2021
Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and
subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59.
doi:10.1177/10…
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psnet.ahrq.gov/node/41647/psn-pdf
July 02, 2014 - Seen through their eyes: residents' reflections on the
cognitive and contextual components of diagnostic errors
in medicine.
July 2, 2014
Ogdie AR, Reilly JB, Pang WG, et al. Seen through their eyes: residents' reflections on the cognitive and
contextual components of diagnostic errors in medicine. Acad Med. 2012;…
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psnet.ahrq.gov/node/43072/psn-pdf
November 21, 2016 - Physician attitudes toward family-activated medical
emergency teams for hospitalized children.
November 21, 2016
Paciotti B, Roberts KE, Tibbetts KM, et al. Physician attitudes toward family-activated medical emergency
teams for hospitalized children. Jt Comm J Qual Patient Saf. 2014;40(4):187-192.
https://psnet.a…
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psnet.ahrq.gov/node/39543/psn-pdf
May 19, 2010 - Hospital Survey on Patient Safety Culture: 2010 User
Comparative Database Report.
May 19, 2010
Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and
Quality; March 2010. AHRQ Publication No. 10-0026.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-20…