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psnet.ahrq.gov/issue/getting-root-medication-errors
March 21, 2009 - Study
Getting to the root of medication errors.
Citation Text:
Cohen H, Shastay AD. Getting to the root of medication errors. Nursing (Brux). 2008;38(12):39-49. doi:10.1097/01.NURSE.0000342031.85246.a1.
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psnet.ahrq.gov/issue/wrong-site-surgery-otolaryngology-head-and-neck-surgery
March 03, 2021 - Review
Wrong site surgery in otolaryngology–head and neck surgery.
Citation Text:
Liou T-N, Nussenbaum B. Wrong site surgery in otolaryngology-head and neck surgery. Laryngoscope. 2014;124(1):104-109. doi:10.1002/lary.24140.
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psnet.ahrq.gov/issue/blind-spots-science-safety
February 24, 2021 - Commentary
Blind spots in the science of safety.
Citation Text:
Bosk CL, Pedersen KZ. Blind spots in the science of safety. Lancet. 2019;393(10175):978-979. doi:10.1016/S0140-6736(19)30441-6.
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psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
March 10, 2021 - Toolkit
Health IT Safe Practices for Closing the Loop.
Citation Text:
Health IT Safe Practices for Closing the Loop. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
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psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
April 01, 2020 - Book/Report
Medication Overload: America's Other Drug Problem.
Citation Text:
Medication Overload: America's Other Drug Problem. Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
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psnet.ahrq.gov/issue/adherence-medication-safety-protocol-current-practice-labeling-medications-and-solutions
July 19, 2023 - Study
Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.
Citation Text:
Brown-Brumfield D, DeLeon A. Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile f…
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psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care
March 10, 2021 - Book/Report
Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.
Citation Text:
Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
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psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards
February 09, 2022 - Newspaper/Magazine Article
Start the new year off right by preventing these top 10 medication errors and hazards.
Citation Text:
Start the new year off right by preventing these top 10 medication errors and hazards. ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2)…
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psnet.ahrq.gov/issue/circle-training
February 22, 2023 - Multi-use Website
Circle Up Training.
Citation Text:
Circle Up Training. Center for Medical Simulation.
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psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine
July 30, 2014 - Review
Overconfidence as a cause of diagnostic error in medicine.
Citation Text:
Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2-S23. doi:10.1016/j.amjmed.2008.01.001.
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psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
October 11, 2016 - Book/Report
Cognitive Systems Engineering in Health Care.
Citation Text:
Cognitive Systems Engineering in Health Care. Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.
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psnet.ahrq.gov/issue/wide-heart-monitor-use-tied-missed-alarms
July 19, 2023 - Newspaper/Magazine Article
Wide heart monitor use tied to missed alarms.
Citation Text:
Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use o…
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psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
September 12, 2016 - Commentary
Promoting civility in the OR: an ethical imperative.
Citation Text:
Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66. doi:10.1016/j.aorn.2016.10.019.
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psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-increase-safety-event-reporting
August 08, 2018 - Commentary
Understanding the root cause analysis process to increase safety event reporting.
Citation Text:
Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J. 2023;117(6):399-402. doi:10.1002/aorn.13935.
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psnet.ahrq.gov/issue/creating-safety-culture-nursing-units-human-performance-and-organizational-system-factors
May 29, 2013 - Study
Creating safety culture on nursing units: human performance and organizational system factors that make a difference.
Citation Text:
Moody RF, Pesut DJ, Harrington CF. Creating Safety Culture on Nursing Units. J Patient Saf. 2008;2(4). doi:10.1097/01.jps.0000242978.40424.24.
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psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing
November 01, 2017 - Newspaper/Magazine Article
Mean girls of the ER: the alarming nurse culture of bullying and hazing.
Citation Text:
Mean girls of the ER: the alarming nurse culture of bullying and hazing. Robbins A. Good Housekeeping. May 20, 2016.
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psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-reliability-outcomes
March 14, 2023 - Newspaper/Magazine Article
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
Citation Text:
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! …
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psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
February 10, 2021 - Newspaper/Magazine Article
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error
Citation Text:
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.
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psnet.ahrq.gov/issue/fatal-solutions-how-healthcare-system-used-tragedy-transform-itself-and-redefine-just-culture
May 16, 2019 - Book/Report
Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture.
Citation Text:
Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. Davies JM, Steinke C, Flemons WW. New York, NY: Productivit…
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psnet.ahrq.gov/issue/secondary-care-nursing-perspective-medication-administration-safety
July 23, 2010 - Study
A secondary care nursing perspective on medication administration safety.
Citation Text:
McBride-Henry K, Foureur M. A secondary care nursing perspective on medication administration safety. J Adv Nurs. 2007;60(1):58-66.
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