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psnet.ahrq.gov/issue/have-we-gone-too-far-translating-ideas-aviation-patient-safety
March 06, 2005 - Commentary
Have we gone too far in translating ideas from aviation to patient safety?
Citation Text:
Have we gone too far in translating ideas from aviation to patient safety? Rogers J, Gaba DM. BMJ. 2011;342:c7309-c7310.
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psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party
February 08, 2011 - Government Resource
Guidance on Safe Medical Staffing: Report of a Working Party.
Citation Text:
Guidance on Safe Medical Staffing: Report of a Working Party. London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
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psnet.ahrq.gov/issue/team-communication-operating-room
January 28, 2009 - Commentary
Team communication in the operating room.
Citation Text:
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49(7):898-901.
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psnet.ahrq.gov/issue/2010-annual-national-patient-safety-foundation-congress-conference-proceedings
July 31, 2012 - Commentary
2010 Annual National Patient Safety Foundation Congress: conference proceedings.
Citation Text:
Pinakiewicz DC, Bonacum D, Youngberg BJ, et al. 2010 Annual National Patient Safety Foundation Congress: conference proceedings. J Patient Saf. 2010;6(3):128-36.
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psnet.ahrq.gov/issue/tragic-death-time-blame-or-time-learn
March 23, 2011 - Commentary
A tragic death: a time to blame or a time to learn?
Citation Text:
Runciman WB, Merry AF. A tragic death: a time to blame or a time to learn? Qual Saf Health Care. 2003;12(5):321-2.
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - Newsletter/Journal
ISMP Long-Term Care Advise-ERR.
Citation Text:
ISMP Long-Term Care Advise-ERR. Horsham, PA; Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/quantitative-analysis-adverse-events-neurosurgery
September 25, 2019 - Study
Quantitative analysis of adverse events in neurosurgery.
Citation Text:
Houkin K, Baba T, Minamida Y, et al. Quantitative analysis of adverse events in neurosurgery. Neurosurgery. 2009;65(3):587-94; discussion 594. doi:10.1227/01.NEU.0000350860.59902.68.
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psnet.ahrq.gov/issue/strengthening-core-middle-managers-play-vital-role-improving-safety
April 25, 2016 - Newspaper/Magazine Article
Strengthening the core. Middle managers play a vital role in improving safety.
Citation Text:
Federico F, Bonacum D. Strengthening the core. Middle managers play a vital role in improving safety. Healthcare executive. 2010;25(1):68-70.
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psnet.ahrq.gov/issue/white-blood-cell-left-shift-neonate-case-mistaken-identity
March 30, 2022 - Commentary
White blood cell left shift in a neonate: a case of mistaken identity.
Citation Text:
White blood cell left shift in a neonate: a case of mistaken identity. Mohamed IS; Wynn RJ; Cominsky K; Reynolds AM; Ryan RM; Kumar VH; Lakshminrusimha S.
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psnet.ahrq.gov/issue/use-systems-redesign-and-law-prevent-medical-errors-and-accidents
August 26, 2020 - Newspaper/Magazine Article
Use systems redesign and the law to prevent medical errors and accidents.
Citation Text:
Use systems redesign and the law to prevent medical errors and accidents. Saks MJ, Landsman S. STAT. August 4, 2021.
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psnet.ahrq.gov/issue/farewell-cancer-never-was
April 12, 2011 - Commentary
Farewell to a cancer that never was.
Citation Text:
Lyon J. Farewell to a Cancer That Never Was. JAMA. 2017;317(18):1824-1825. doi:10.1001/jama.2017.3969.
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psnet.ahrq.gov/issue/becoming-high-reliability-organization
May 04, 2015 - Special or Theme Issue
Becoming a High Reliability Organization.
Citation Text:
Becoming a High Reliability Organization. VHA Forum. Summer 2020;1-12.
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psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
August 04, 2021 - Tools/Toolkit
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence.
Citation Text:
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. Houston TX; Baylor College of Medicine: 2022.
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psnet.ahrq.gov/issue/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-non-profiled
May 07, 2014 - Newspaper/Magazine Article
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.
Citation Text:
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. ISMP Medication …
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psnet.ahrq.gov/issue/adoption-electronic-medical-record-technology-order-prevent-medical-errors-matter-american
March 07, 2018 - Commentary
The adoption of electronic medical record technology in order to prevent medical errors: a matter for American public policy.
Citation Text:
The adoption of electronic medical record technology in order to prevent medical errors: a matter for American public policy. Crane JN; …
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psnet.ahrq.gov/issue/computer-technology-and-clinical-work-still-waiting-godot
October 19, 2022 - Commentary
Computer technology and clinical work: still waiting for Godot.
Citation Text:
Wears RL, Berg M. Computer Technology and Clinical Work. JAMA. 2005;293(10). doi:10.1001/jama.293.10.1261.
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psnet.ahrq.gov/issue/dana-farber-cancer-institute-principles-fair-and-just-culture
January 11, 2023 - Organizational Policy/Guidelines
Dana-Farber Cancer Institute Principles of a Fair and Just Culture.
Citation Text:
Dana-Farber Cancer Institute Principles of a Fair and Just Culture. Dana-Farber Cancer Institute.
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psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors
November 01, 2023 - Newspaper/Magazine Article
Unreadable barcodes and multiple barcodes on packages can lead to errors.
Citation Text:
Unreadable barcodes and multiple barcodes on packages can lead to errors. ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3.
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psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-physicians
December 15, 2021 - Book/Report
New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians.
Citation Text:
New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 978311…
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psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk-infections
June 12, 2018 - Newspaper/Magazine Article
Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.
Citation Text:
Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections. ISMP Medication Safety Alert! Acute Care Edition. Septem…