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psnet.ahrq.gov/issue/complementary-telephone-strategies-improve-postdischarge-communication
July 02, 2014 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
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psnet.ahrq.gov/issue/perspective-road-map-academic-departments-promote-scholarship-quality-improvement-and-patient
July 02, 2014 - March 30, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/improved-prophylaxis-and-decreased-rates-preventable-harm-use-mandatory-computerized-clinical
June 21, 2016 - February 19, 2014
Error in body weight estimation leads to inadequate parenteral anticoagulation
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psnet.ahrq.gov/issue/development-patient-safety-program-across-continuum-care
September 21, 2009 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
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psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
August 13, 2008 - May 11, 2019
Electronic prescribing vulnerabilities: height and weight mix-up leads to
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psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
January 23, 2012 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads
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psnet.ahrq.gov/issue/reduction-chemotherapy-order-errors-computerised-physician-order-entry-and-clinical-decision
October 22, 2014 - October 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/issue/effectiveness-toyota-process-redesign-reducing-thyroid-gland-fine-needle-aspiration-error
June 14, 2011 - January 15, 2014
When diagnostic testing leads to harm: a new outcomes-based approach
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psnet.ahrq.gov/issue/negotiating-medical-virtues-toward-development-physician-mistake-disclosure-model
June 14, 2017 - June 14, 2011
A medical error leads to tragedy: how do we inform the patient?
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psnet.ahrq.gov/issue/medical-trainees-formal-and-informal-incident-reporting-across-five-hospital-academic-medical
May 10, 2016 - June 15, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
May 20, 2015 - February 17, 2011
A medical error leads to tragedy: how do we inform the patient?
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psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
May 02, 2018 - May 7, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads to
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psnet.ahrq.gov/issue/normalization-deviance-do-we-unknowingly-accept-doing-wrong-thing
May 23, 2018 - March 27, 2024
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/maximizing-smart-pump-technology-enhance-patient-safety
April 25, 2018 - May 5, 2018
Misprogramming PCA concentration leads to dosing errors.
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psnet.ahrq.gov/issue/mortality-measure-quality-implications-palliative-and-end-life-care
June 30, 2011 - March 2, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - December 2, 2015
The absence of a drug–disease interaction alert leads to a child's death
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-25-pioneering-success-safety-25th-anniversary-provokes
January 01, 2015 - January 13, 2013
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/path-safe-and-reliable-healthcare
August 20, 2018 - August 26, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon
June 12, 2013 - July 30, 2014
When diagnostic testing leads to harm: a new outcomes-based approach for