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psnet.ahrq.gov/node/46515/psn-pdf
December 22, 2018 - A contemporary medicolegal analysis of outpatient
medication management in chronic pain.
December 22, 2018
Abrecht CR, Brovman EY, Greenberg P, et al. A Contemporary Medicolegal Analysis of Outpatient
Medication Management in Chronic Pain. Anesth Analg. 2017;125(5):1761-1768.
doi:10.1213/ANE.0000000000002499.
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psnet.ahrq.gov/node/38961/psn-pdf
September 01, 2016 - An empirical model to estimate the potential impact of
medication safety alerts on patient safety, health care
utilization, and cost in ambulatory care.
September 1, 2016
Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of
medication safety alerts on patient safety,…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - They concluded that each interruption results in a 12.7% increased risk of a medication error and that … individually and collectively, to ensure that they actually do reduce the frequency and severity of medication … errors without negative unanticipated consequences.( 5 )
Certain clinical environments such as the … errors ( 14 ) or interruptions.( 2 ) The adoption of this strategy appears somewhat limited perhaps … Keep away: Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors
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psnet.ahrq.gov/issue/special-issue-patient-safety
August 22, 2007 - May 6, 2020
Systemic causes of in-hospital intravenous medication errors: a systematic
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psnet.ahrq.gov/node/845360/psn-pdf
March 29, 2023 - traumatic brain injury, or stroke) are
particularly vulnerable to patient safety events, such as falls and medication … errors.
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Review of nationally reported opioid-related sentinel events
found that 75% were attributable to medication … error and
improper monitoring
12
Opioid-Induced Respiratory Depression (3) 13
• Majority of PCA … Medication errors involving patient-controlled analgesia.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/issue/detection-adverse-events-acute-geriatric-hospital-over-6-year-period-using-global-trigger
March 09, 2022 - Study
Detection of adverse events in an acute geriatric hospital over a 6-year period using the Global Trigger Tool.
Citation Text:
Suarez C, Menendez MD, Alonso J, et al. Detection of adverse events in an acute geriatric hospital over a 6-year period using the Global Trigger Tool. J Am …
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psnet.ahrq.gov/issue/impact-sleep-deprivation-product-quality-and-procedure-effectiveness-laparoscopic-physical
June 03, 2020 - Study
The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator: a randomized controlled trial.
Citation Text:
Uchal M, Tjugum J, Martinsen E, et al. The impact of sleep deprivation on product quality and procedure effectivene…
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psnet.ahrq.gov/issue/adoption-national-quality-forum-safe-practices-magnet-hospitals
May 15, 2019 - Study
Adoption of National Quality Forum safe practices by magnet hospitals.
Citation Text:
Jayawardhana J, Welton JM, Lindrooth R. Adoption of National Quality Forum Safe Practices by Magnet® Hospitals. JONA: The Journal of Nursing Administration. 2011;41(9). doi:10.1097/nna.0b013e318…
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psnet.ahrq.gov/issue/agreement-expert-judgment-causality-assessment-adverse-drug-reactions
November 29, 2023 - Study
Agreement of expert judgment in causality assessment of adverse drug reactions.
Citation Text:
Arimone Y, Bégaud B, Miremont-Salamé G, et al. Agreement of expert judgment in causality assessment of adverse drug reactions. Eur J Clin Pharmacol. 2005;61(3):169-73.
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psnet.ahrq.gov/issue/bar-coding-surgical-sponges-improve-safety-randomized-controlled-trial
March 02, 2011 - Study
Classic
Bar-coding surgical sponges to improve safety: a randomized controlled trial.
Citation Text:
Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding Surgical Sponges To Improve Safety. Ann Surg. 2009;247(4). doi:10.1097/sla.0b013e3181656cd5.…
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psnet.ahrq.gov/issue/assessment-attitudes-toward-deprescribing-older-medicare-beneficiaries-united-states
June 30, 2021 - Study
Classic
Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States.
Citation Text:
Reeve E, Wolff JL, Skehan M, et al. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States.…
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psnet.ahrq.gov/issue/what-do-patients-and-families-observe-about-pediatric-safety-thematic-analysis-real-time
March 02, 2022 - Study
What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives.
Citation Text:
Studenmund C, Lyndon A, Stotts JR, et al. What do patients and families observe about pediatric safety?: A thematic analysis of real‐time narratives. J Hosp Me…
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psnet.ahrq.gov/issue/nurses-perceptions-electronic-patient-record-patient-safety-perspective-qualitative-study
October 09, 2013 - Study
Nurses' perceptions of an electronic patient record from a patient safety perspective: a qualitative study.
Citation Text:
Stevenson JE, Nilsson G. Nurses' perceptions of an electronic patient record from a patient safety perspective: a qualitative study. J Adv Nurs. 2012;68(3):6…
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psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-patient-safety-program
January 04, 2017 - Study
Closing the loop: follow-up and feedback in a patient safety program.
Citation Text:
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
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psnet.ahrq.gov/issue/omissions-care-nursing-home-settings-narrative-review
November 18, 2020 - Review
Omissions of care in nursing home settings: a narrative review.
Citation Text:
Ogletree AM, Mangrum R, Harris Y, et al. Omissions of care in nursing home settings: a narrative review. J Am Med Dir Assoc. 2020;21(5):604-614.e6. doi:10.1016/j.jamda.2020.02.016.
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psnet.ahrq.gov/issue/improving-safety-during-transitions-care-through-use-electronic-referral-loops-receive-and
October 19, 2022 - Study
Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.
Citation Text:
Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic referral loops to receiv…
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psnet.ahrq.gov/issue/using-simulation-augment-root-cause-analysis-patient-safety-incidents-tertiary-care-womens
January 22, 2025 - Study
Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study.
Citation Text:
Burchell D, MacPhee S, Sinclair D, et al. Using simulation to augment root cause analysis for patient saf…
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psnet.ahrq.gov/issue/interventions-targeted-reducing-diagnostic-error-systematic-review
March 10, 2021 - Review
Interventions targeted at reducing diagnostic error: systematic review.
Citation Text:
Dave N, Bui S, Morgan C, et al. Interventions targeted at reducing diagnostic error: systematic review. BMJ Qual Saf. 2022;31(4):297-307. doi:10.1136/bmjqs-2020-012704.
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