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psnet.ahrq.gov/issue/still-crossing-quality-chasm
November 04, 2012 - November 18, 2011
ISMP medication error report analysis.
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psnet.ahrq.gov/node/38118/psn-pdf
October 01, 2019 - Preventing errors relating to commonly used
anticoagulants.
December 23, 2016
Preventing errors relating to commonly used anticoagulants. Sentinel Event Alert. 2008;41(41):1-4.
https://psnet.ahrq.gov/issue/preventing-errors-relating-commonly-used-anticoagulants
Anticoagulant therapies such as heparin and warfarin …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - Intensive Insulin Therapy
Automated order sets and preprinted order sheets
Effective in reducing medication … errors related to chemotherapy dosing
Effective in ensuring appropriate therapy for myocardial infarction
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psnet.ahrq.gov/node/43193/psn-pdf
June 17, 2014 - Risks in the implementation and use of smart pumps in a
pediatric intensive care unit: application of the failure
mode and effects analysis.
June 17, 2014
Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of
smart pumps in a pediatric intensive care unit: applicati…
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psnet.ahrq.gov/issue/challenges-transparency-reporting-medical-errors
July 19, 2023 - Commentary
The challenges to transparency in reporting medical errors.
Citation Text:
Paterick ZR, Paterick BB, Waterhouse BE, et al. The Challenges to Transparency in Reporting Medical Errors. J Patient Saf. 2009;5(4). doi:10.1097/pts.0b013e3181be2a88.
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psnet.ahrq.gov/node/43673/psn-pdf
November 19, 2014 - Work-arounds observed by fourth-year nursing students.
November 19, 2014
Westphal J, Lancaster R, Park D. Work-Arounds Observed by Fourth-Year Nursing Students. West J Nurs
Res. 2014;36(8):1002-18. doi:10.1177/0193945913511707.
https://psnet.ahrq.gov/issue/work-arounds-observed-fourth-year-nursing-students
Accordi…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - April 29, 2018
NICU medication errors: identifying a risk profile for medication errors
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psnet.ahrq.gov/issue/reportable-incidents
November 02, 2016 - Newspaper/Magazine Article
Reportable incidents.
Citation Text:
Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7.
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Google Scholar PubMed BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/issue/learning-malpractice-claims-about-negligent-adverse-events-primary-care-united-states
April 07, 2011 - Study
Learning from malpractice claims about negligent, adverse events in primary care in the United States.
Citation Text:
Phillips RL, Bartholomew LA, Dovey S, et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Healt…
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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/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
May 13, 2009 - Book/Report
Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition.
Citation Text:
Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition. Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 978…
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psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
June 16, 2009 - Study
Usability study of two common defibrillators reveals hazards.
Citation Text:
Fairbanks RJ, Caplan SH, Bishop PA, et al. Usability Study of Two Common Defibrillators Reveals Hazards. Ann Emerg Med. 2007;50(4):424-432. doi:10.1016/j.annemergmed.2007.03.029.
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psnet.ahrq.gov/issue/clinical-questions-raised-clinicians-point-care-systematic-review
May 04, 2022 - Review
Clinical questions raised by clinicians at the point of care: a systematic review.
Citation Text:
Del Fiol G, Workman E, Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014;174(5):710-8. doi:10.1001/jamainternmed.2014…
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psnet.ahrq.gov/issue/insights-climate-safety-towards-prevention-falls-among-hospital-staff
February 14, 2017 - Study
Insights into the climate of safety towards the prevention of falls among hospital staff.
Citation Text:
Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.111…
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psnet.ahrq.gov/issue/review-educational-philosophies-applied-radiation-safety-training-medical-institutions
May 31, 2017 - Commentary
A review of educational philosophies as applied to radiation safety training at medical institutions.
Citation Text:
Dauer LT, St Germain J. A review of educational philosophies as applied to radiation safety training at medical institutions. Health Phys. 2006;90(5 Suppl):S6…
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psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
February 15, 2011 - Commentary
Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.
Citation Text:
Pietrobon R, Lima R, Shah A, et al. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-mi…
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psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
October 19, 2022 - Commentary
Infusing fun into quality and safety initiatives.
Citation Text:
Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux). 2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9.
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/effect-collaboration-obstetric-patient-safety-three-academic-facilities
October 19, 2022 - Commentary
The effect of collaboration on obstetric patient safety in three academic facilities.
Citation Text:
Raab CA, Will SEB, Richards SL, et al. The Effect of Collaboration on Obstetric Patient Safety in Three Academic Facilities. Journal of Obstetric, Gynecologic & Neonatal Nursi…
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-25-pioneering-success-safety-25th-anniversary-provokes
January 01, 2015 - Commentary
The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.
Citation Text:
Eichhorn JH. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection,…