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psnet.ahrq.gov/node/50399/psn-pdf
January 01, 2020 - Building the bridge to quality: an urgent call to integrate
quality improvement and patient safety education with
clinical care
October 2, 2019
Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality
improvement and patient safety education with clinical care. Acad…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/node/46239/psn-pdf
January 01, 2021 - Identifying high-alert medications in a university hospital
by applying data from the medication error reporting
system.
August 16, 2017
Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by
Applying Data From the Medication Error Reporting System. J Patient Sa…
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psnet.ahrq.gov/node/36391/psn-pdf
December 22, 2010 - Safety in numbers.
December 22, 2010
Robeznieks A.
https://psnet.ahrq.gov/issue/safety-numbers
This article discusses the Leapfrog Group's first annual list of "Top Hospitals" (according to the group's
quality standards) and the health care industry's response to the list and the measures used to create it.
https…
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psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion
May 03, 2023 - Newspaper/Magazine Article
Smart infusion pump investigations after an unexplained over-infusion.
Citation Text:
Smart infusion pump investigations after an unexplained over-infusion. ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.
Copy Citation
…
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psnet.ahrq.gov/issue/using-consumer-based-kiosk-technology-improve-and-standardize-medication-reconciliation
August 23, 2023 - Study
Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting.
Citation Text:
Lesselroth B, Adams S, Felder R, et al. Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty c…
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psnet.ahrq.gov/issue/using-electronic-prescribing-system-ensure-accurate-medication-lists-large-multidisciplinary
August 28, 2017 - Study
Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group.
Citation Text:
Stock R, Scott J, Gurtel S. Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group. J…
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psnet.ahrq.gov/node/73566/psn-pdf
August 04, 2021 - Personal formularies of primary care physicians across 4
health care systems.
August 4, 2021
Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health
care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/837432/psn-pdf
June 15, 2022 - Adopt strategies to manage look-alike and/or sound-alike
medication name mix-ups.
June 15, 2022
ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.
https://psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-
ups
Minimizing look-alike/sound-alike me…
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psnet.ahrq.gov/node/50834/psn-pdf
January 29, 2020 - Medication reconciliation improvement utilizing process
redesign and clinical decision support.
January 29, 2020
Rungvivatjarus T, Kuelbs CL, Miller L, et al. Medication Reconciliation Improvement Utilizing Process
Redesign and Clinical Decision Support. Jt Comm J Qual Patient Saf. 2020;46(1):27-36.
doi:10.1016/j.…
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psnet.ahrq.gov/node/36713/psn-pdf
April 29, 2018 - Reducing patient harm from opiates.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. February 22, 2007.
https://psnet.ahrq.gov/issue/reducing-patient-harm-opiates
This article lists common risks associated with opiates, a high-alert medication, as well as recommended
safety improvements to reduce t…
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psnet.ahrq.gov/node/74027/psn-pdf
November 03, 2021 - Staffing levels and nursing-sensitive patient outcomes:
umbrella review and qualitative study.
November 3, 2021
Blume KS, Dietermann K, Kirchner?Heklau U, et al. Staffing levels and nursing?sensitive patient outcomes:
umbrella review and qualitative study. Health Serv Res. 2021;56(5):885-907. doi:10.1111/1475-
677…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
For…
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psnet.ahrq.gov/issue/what-else-could-it-be-scoping-review-questions-patients-ask-throughout-diagnostic-process
November 03, 2021 - Review
"What else could it be?" A scoping review of questions for patients to ask throughout the diagnostic process.
Citation Text:
Hill MA, Coppinger T, Sedig K, et al. "What else could it be?" A scoping review of questions for patients to ask throughout the diagnostic process. J Patien…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - following evening, the patient's mother called the ED to report that the patient's discharge paperwork listed … Still, I and the organizations listed above believe it is safest and should be standard of practice to
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - At
this hospital, the CPOE system listed each choice twice, one entry with the generic name and one … https://psnet.ahrq.gov//#table
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#table
listed
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psnet.ahrq.gov/issue/patient-safety-dentistry-development-candidate-never-event-list-primary-care
April 12, 2017 - Study
Patient safety in dentistry: development of a candidate 'never event' list for primary care.
Citation Text:
Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456.
…
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psnet.ahrq.gov/issue/anybody-list-youre-more-worried-about-qualitative-analysis-exploring-functions-questions
January 22, 2016 - Study
"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.
Citation Text:
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?" Qualitative analysis expl…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - Munier : A Patient Safety Organization is a new or existing organization that applies to be officially listed … CHPSO easily complied with the listing requirements, and became the second listed PSO in the nation. … Getting a PSO listed and functioning can be rather "cookbook"—the PSQIA and its associated rules are