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psnet.ahrq.gov/node/35397/psn-pdf
September 10, 2009 - The National Medical Error Disclosure and Compensation
(MEDiC) Act.
September 10, 2009
Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005.
https://psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act
This bill, introduced to the Senate by Senators Clint…
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psnet.ahrq.gov/node/41293/psn-pdf
June 01, 2012 - Developing an action plan for patient radiation safety in
adult cardiovascular medicine.
June 1, 2012
Douglas PS, Carr J, Cerqueira MD, et al. Developing an action plan for patient radiation safety in adult
cardiovascular medicine: proceedings from the Duke University Clinical Research Institute/American
College o…
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psnet.ahrq.gov/node/38913/psn-pdf
May 24, 2015 - Thinking Outside the Pillbox: A System-wide Approach to
Improving Patient Medication Adherence for Chronic
Disease.
May 24, 2015
Cambridge, MA: New England Healthcare Institute; August 12, 2009.
https://psnet.ahrq.gov/issue/thinking-outside-pillbox-system-wide-approach-improving-patient-medication-
adherence-chro…
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psnet.ahrq.gov/node/37053/psn-pdf
July 31, 2008 - Electronic health record use and the quality of ambulatory
care in the United States.
July 31, 2008
Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the
United States. Arch Intern Med. 2007;167(13):1400-5.
https://psnet.ahrq.gov/issue/electronic-health-record-use…
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psnet.ahrq.gov/node/47025/psn-pdf
April 11, 2018 - Chemotherapy medication errors.
April 11, 2018
Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol.
2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9.
https://psnet.ahrq.gov/issue/chemotherapy-medication-errors
Chemotherapy errors can result in serious patient harm. This revi…
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psnet.ahrq.gov/node/41062/psn-pdf
July 02, 2014 - Perspective: a road map for academic departments to
promote scholarship in quality improvement and patient
safety.
July 2, 2014
Neeman N, Sehgal NL. Perspective: a road map for academic departments to promote scholarship in
quality improvement and patient safety. Acad Med. 2012;87(2):168-71.
doi:10.1097/ACM.0b013…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/42028/psn-pdf
February 18, 2014 - Warning! Severe burns and permanent scarring after
glacial acetic acid (?99.5%) mistakenly applied topically.
February 18, 2014
National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System
Pharmacists and Institute for Safe Medication Practices; January 23, 2013.
https://ps…
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psnet.ahrq.gov/node/45176/psn-pdf
July 20, 2016 - Sustaining Improvement.
July 20, 2016
Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement;
2016.
https://psnet.ahrq.gov/issue/sustaining-improvement
Numerous activities and programs have been launched to improve patient safety, but sustaining
improvements can be …
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psnet.ahrq.gov/node/34668/psn-pdf
June 06, 2018 - Please don't sleep through this wake-up call.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
https://psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error
that occu…
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psnet.ahrq.gov/node/48136/psn-pdf
August 07, 2019 - Safe Practices for Drug Allergies—Using CDS and Health
IT.
August 7, 2019
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/safe-practices-drug-allergies-using-cds-and-health-it
Inconsistent checking for and consideration of drug allergy alerts can d…
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psnet.ahrq.gov/node/40869/psn-pdf
October 26, 2011 - Patient safety outcomes: the importance of
understanding the organizational culture and safety
climate.
October 26, 2011
Ross J. Patient safety outcomes: the importance of understanding the organizational culture and safety
climate. J Perianesth Nurs. 2011;26(5):347-8. doi:10.1016/j.jopan.2011.08.001.
https://psn…
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psnet.ahrq.gov/node/866531/psn-pdf
August 14, 2024 - The Impact of Artificial Intelligence (AI) on the Safety of
Patients.
August 14, 2024
Institute for Healthcare Improvement. The Impact of Artificial Intelligence (AI) on the Safety of Patients. .
https://psnet.ahrq.gov/issue/impact-artificial-intelligence-ai-safety-patients
Artificial intelligence (AI) is rapidly …
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psnet.ahrq.gov/node/37576/psn-pdf
May 24, 2015 - Saving Lives, Saving Money: The Imperative for
Computerized Physician Order Entry in Massachusetts
Hospitals.
May 24, 2015
Adams M, Bates D, Coffman G, et al. Boston, MA: Massachusetts Technology Collaborative; New England
Healthcare Institute; February 2008.
https://psnet.ahrq.gov/issue/saving-lives-saving-money…
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psnet.ahrq.gov/node/38361/psn-pdf
January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue,
improve patient safety.
January 31, 2011
Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA.
2009;301(3):259-61. doi:10.1001/jama.2008.940.
https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…
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psnet.ahrq.gov/node/37023/psn-pdf
September 24, 2010 - Applying the Toyota Production System: using a patient
safety alert system to reduce error.
September 24, 2010
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to
reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
https://psnet.ahrq.gov/issue/applying-toyot…
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psnet.ahrq.gov/node/38305/psn-pdf
January 15, 2009 - High-alert medications in the pediatric intensive care unit.
January 15, 2009
Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care
Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8.
https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c…
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psnet.ahrq.gov/node/44223/psn-pdf
November 22, 2016 - Patient Safety and Incident Management Toolkit.
November 22, 2016
Edmonton, AB: Canadian Patient Safety Institute. June 2015.
https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit
Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-
compone…
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psnet.ahrq.gov/node/44502/psn-pdf
May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic
Medication Information.
May 7, 2018
Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6.
https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information
How electronic medication-related in…