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psnet.ahrq.gov/node/35743/psn-pdf
July 15, 2010 - ACOG Committee Opinion #327: "Do not use"
abbreviations.
July 15, 2010
ACOG Committee on Quality Improvement and Patient Safety; ACOG.
https://psnet.ahrq.gov/issue/acog-committee-opinion-327-do-not-use-abbreviations
This committee opinion suggests that obstetricians and gynecologists be aware of the "do not use"
…
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psnet.ahrq.gov/node/37896/psn-pdf
March 18, 2010 - Sterile water should not be given "freely."
March 18, 2010
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
https://psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the
treatment of hypernatremia and…
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psnet.ahrq.gov/node/39189/psn-pdf
April 16, 2018 - Neuromuscular blocking agents: reducing associated
wrong-drug errors.
April 16, 2018
https://psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving
neuromuscular blocking agents and s…
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psnet.ahrq.gov/node/35956/psn-pdf
August 02, 2010 - Patient Guide: 10 Ways to Improve Communication with
Your Doctor.
August 2, 2010
Patient Guide: 10 Ways to Improve Communication With Your Doctor. J Patient Saf. 2008;1(4).
doi:10.1097/01.jps.0000199856.82316.50.
https://psnet.ahrq.gov/issue/patient-guide-10-ways-improve-communication-your-doctor
This article lis…
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psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - Age ranges listed are different for the oral suspension (infant and 2-11) versus the rapidly dissolved
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - to limit errors associated with these medications, focusing on
thrombolysis.(8) The principles are listed
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - routine testing ordered by his
primary care doctor but also for the genetic screening, because it was listed
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psnet.ahrq.gov/node/36243/psn-pdf
September 06, 2006 - The Food and Drug Administration's National Drug Code
Directory.
September 6, 2006
Levinson DR. Washington DC; Office of the Inspector General, US Department of Health and Human
Services: August 2006. Report no OEI-06-05-00060.
https://psnet.ahrq.gov/issue/food-and-drug-administrations-national-drug-code-directory…
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psnet.ahrq.gov/node/37149/psn-pdf
January 02, 2017 - Preventing harm from high-alert medications.
January 2, 2017
Federico F. Preventing harm from high-alert medications. Jt Comm J Qual Patient Saf. 2007;33(9):537-42.
https://psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
The author discusses strategies to improve medication safety and highlights interve…
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psnet.ahrq.gov/node/37489/psn-pdf
March 03, 2011 - On the trail of quality and safety in health care.
March 3, 2011
Grol R, Berwick DM, Wensing M. On the trail of quality and safety in health care. BMJ. 2008;336(7635):74-
6. doi:10.1136/bmj.39413.486944.AD.
https://psnet.ahrq.gov/issue/trail-quality-and-safety-health-care
This article addresses the gap in health c…
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psnet.ahrq.gov/node/35401/psn-pdf
April 06, 2011 - What constitutes a prescribing error in paediatrics?
April 6, 2011
Ghaleb MA, Barber N, Franklin D, et al. What constitutes a prescribing error in paediatrics? Qual Saf
Health Care. 2005;14(5):352-7.
https://psnet.ahrq.gov/issue/what-constitutes-prescribing-error-paediatrics
The authors used a Delphi technique to …
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Three illustrative cases from the Food and Drug Administration’s Medical Device Reporting system are listed
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psnet.ahrq.gov/node/38972/psn-pdf
January 31, 2019 - From tragedy to advocacy.
January 31, 2019
DerGurahian J. From tragedy to advocacy. Modern healthc. 2009;39(36):6-7, 12, 1.
https://psnet.ahrq.gov/issue/tragedy-advocacy
This article highlights stories of family members who have become influential patient safety advocates
following tragic medical errors. Among tho…
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psnet.ahrq.gov/node/36137/psn-pdf
September 29, 2010 - Rapid response teams: ten essentials leaders need to
know.
September 29, 2010
Dahlen GM, Benz BA. Rapid response teams. Ten essentials leaders need to know. Healthcare executive.
2006;21(4):28-32, 34.
https://psnet.ahrq.gov/issue/rapid-response-teams-ten-essentials-leaders-need-know
The authors list ten points fo…
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psnet.ahrq.gov/node/42956/psn-pdf
February 19, 2014 - Patient safety: it takes a team.
February 19, 2014
Rosemont, IL: American Academy of Orthopaedic Surgeons.
https://psnet.ahrq.gov/issue/patient-safety-it-takes-team
Patient engagement is a promising strategy for error reduction and has become a priority of influential
regulatory and governmental organizations. Thi…
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psnet.ahrq.gov/node/33920/psn-pdf
December 12, 2018 - Policy Positions and Guidelines.
December 12, 2018
Amercian Society of Health-System Pharmacists; ASHP.
https://psnet.ahrq.gov/issue/policy-positions-and-guidelines
This searchable listing of the American Society of Health-System Pharmacists policy and guideline
collection provides user access to various content a…
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psnet.ahrq.gov/node/38423/psn-pdf
September 08, 2010 - Heparin: improving treatment and reducing risk of harm.
September 8, 2010
Daner WE, Gosselin RC, Raschke R, et al. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
https://psnet.ahrq.gov/issue/heparin-improving-treatment-and-reducing-risk-harm
This article explains safety challenges commonly associated w…
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psnet.ahrq.gov/node/35124/psn-pdf
June 29, 2005 - JCAHO proposal for patient-centered care brings concept
to mainstream healthcare settings.
June 29, 2005
ECRI. Risk Management Reporter. June 2005.
https://psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare-
settings
This commentary provides a definition of patient-cent…
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psnet.ahrq.gov/node/39247/psn-pdf
January 27, 2010 - Origins of and solutions for neonatal medication-
dispensing errors.
January 27, 2010
Sauberan JB, Dean LM, Fiedelak J, et al. Origins of and solutions for neonatal medication-dispensing
errors. Am J Health Syst Pharm. 2010;67(1):49-57. doi:10.2146/ajhp090122.
https://psnet.ahrq.gov/issue/origins-and-solutions-neo…
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psnet.ahrq.gov/node/39750/psn-pdf
August 11, 2010 - Medication reconciliation in a community pharmacy
setting.
August 11, 2010
Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting. J
Am Pharm Assoc (2003). 2010;50(4):523-6. doi:10.1331/JAPhA.2010.09121.
https://psnet.ahrq.gov/issue/medication-reconciliation-community-p…