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psnet.ahrq.gov/node/838310/psn-pdf
October 12, 2022 - Intravenous smart pumps at the point of care: a
descriptive, observational study.
October 12, 2022
Giuliano KK, Blake JWC, Bittner NP, et al. Intravenous smart pumps at the point of care: a descriptive,
observational study. J Patient Saf. 2022;18(6):553-558. doi:10.1097/pts.0000000000001057.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
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psnet.ahrq.gov/node/42942/psn-pdf
February 22, 2024 - Targeted Medication Safety Best Practices for Hospitals.
February 22, 2024
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2024.
https://psnet.ahrq.gov/issue/targeted-medication-safety-best-practices-hospitals
This updated report outlines 22 consensus-based best practices to ensure safe medication ad…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Are We Pushing Graduate Nurses Too Fast?
Citation Text:
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - Playing Well with Others: "Translocational Research" in
Patient Safety
September 1, 2005
Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
Perspective
Translation…
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the
Uni…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Adverse Event During Intrahospital Transport
Citation Text:
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - primary challenge of utilizing more than one EHR is mitigating patient safety risks while balancing
institutional
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - primary challenge of utilizing more than one EHR is mitigating patient safety risks while balancing institutional
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - US internal medicine program director perceptions of alignment of graduate medical education and institutional
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Concerted efforts at the
institutional level must be made to identify critical information elements