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psnet.ahrq.gov/issue/effect-therapeutic-interchange-medication-reconciliation-during-hospitalization-and-upon
November 20, 2013 - January 18, 2017
Medication reconciliation accuracy and patient understanding of intended
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psnet.ahrq.gov/issue/real-time-clinical-alerting-effect-automated-paging-system-response-time-critical-laboratory
October 31, 2011 - January 6, 2018
The intended and unintended consequences of communication systems on
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psnet.ahrq.gov/issue/examining-nature-interprofessional-interventions-designed-promote-patient-safety-narrative
August 17, 2018 - November 16, 2022
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Workarounds to intended
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psnet.ahrq.gov/issue/incidence-opioid-misuse-among-surgical-patients-persistent-opioid-use
October 13, 2018 - March 8, 2023
Intended and unintended consequences: changes in opioid prescribing practices
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psnet.ahrq.gov/issue/introduction-rapid-response-system-united-states-veterans-affairs-hospital-reduced-cardiac
January 02, 2017 - March 26, 2015
Intended and unintended effects of large-scale adverse event disclosure
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psnet.ahrq.gov/issue/implementation-sustainment-large-scale-adverse-event-disclosure-support-program-generated
March 26, 2015 - March 26, 2015
Intended and unintended effects of large-scale adverse event disclosure
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psnet.ahrq.gov/node/60518/psn-pdf
May 27, 2020 - Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic.
May 27, 2020
Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-
576R.
https://psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespre…
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psnet.ahrq.gov/node/853070/psn-pdf
August 30, 2023 - Activating pharmacists to reduce the frequency of
medication-related problems (ACTMed): a stepped wedge
cluster randomised trial.
August 30, 2023
Spinks J, Violette R, Boyle DIR, et al. Activating pharmacists to reduce the frequency of medication?related
problems (ACTMed): a stepped wedge cluster randomised trial.…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - circumstances.13 The value of this
technique comes from framing the conversation so that critical information intended
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - it was discovered that the patient had been receiving 0.4 units/min of vasopressin, rather than
the intended
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - • Medication-related CDS in electronic health records (EHRs) is specifically
intended to reduce prescribing
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - —How you say something will affect whether the intended recipient
understands and acts appropriately
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - This color coding was put in place because unintended IV infusion of local anesthetic drugs intended
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - blood cell transfusion: 13 5.11.1 All requests for blood contain two independent identifiers of the intended
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The patient received a daily dose of warfarin five times that of the intended
dose.
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - demonstration of PICC line care and maintenance will reduce risks and ensure the PICC functions as intended
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Pre-printed order forms and templates are in part intended to improve the completeness, accuracy, and … The intern may have intended to substitute abacavir for stavudine in the original drug combination by
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psnet.ahrq.gov/node/43516/psn-pdf
June 15, 2017 - Application of failure mode effect analysis to improve the
care of septic patients admitted through the emergency
department.
June 15, 2017
Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of
Septic Patients Admitted Through the Emergency Department. J Patient …
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psnet.ahrq.gov/node/45436/psn-pdf
August 31, 2016 - Improving the communication between teams managing
boarded patients on a surgical specialty ward.
August 31, 2016
Puvaneswaralingam S, Ross D. Improving the communication between teams managing boarded patients
on a surgical specialty ward. BMJ Qual Improv Rep. 2016;5(1). doi:10.1136/bmjquality.u209186.w3750.
http…
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psnet.ahrq.gov/node/36797/psn-pdf
August 26, 2011 - The American College of Surgeons' closed claims study:
new insights for improving care.
August 26, 2011
Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons’ Closed Claims Study:
New Insights for Improving Care. J Am Coll Surg. 2007;204(4). doi:10.1016/j.jamcollsurg.2007.01.013.
https://p…