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  1. Psn-Pdf (pdf file)

    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…
  2. 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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. 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 …
  6. 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…
  7. 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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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.…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. 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…
  16. 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
  17. Psn-Pdf (pdf file)

    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
  18. 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. …
  19. 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…
  20. 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

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