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psnet.ahrq.gov/node/43405/psn-pdf
August 14, 2014 - Characteristics associated with postdischarge medication
errors.
August 14, 2014
Mixon A, Myers AP, Leak CL, et al. Characteristics associated with postdischarge medication errors. Mayo
Clin Proc. 2014;89(8):1042-51. doi:10.1016/j.mayocp.2014.04.023.
https://psnet.ahrq.gov/issue/characteristics-associated-postdisc…
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psnet.ahrq.gov/node/40384/psn-pdf
April 20, 2011 - A "back to basics" approach to reduce ED medication
errors.
April 20, 2011
Blank FSJ, Tobin J, Macomber S, et al. A "back to basics" approach to reduce ED medication errors.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association.
2011;37(2):141-7. doi:10.1016/j.jen.…
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psnet.ahrq.gov/node/37755/psn-pdf
April 14, 2011 - An iconic language for the graphical representation of
medical concepts.
April 14, 2011
Lamy J-B, Duclos C, Bar-Hen A, et al. An iconic language for the graphical representation of medical
concepts. BMC Med Inform Decis Mak. 2008;8:16. doi:10.1186/1472-6947-8-16.
https://psnet.ahrq.gov/issue/iconic-language-graphi…
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psnet.ahrq.gov/node/36180/psn-pdf
September 29, 2010 - Why nurses make medication errors: a simulation study.
September 29, 2010
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ
Today. 2007;27(4):312-7.
https://psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
The investigators used a simulate…
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psnet.ahrq.gov/node/36388/psn-pdf
June 12, 2013 - Using patient safety science to explore strategies for
improving safety in intravenous medication
administration.
June 12, 2013
Franklin M. Journal of the Association for Vascular Access. 2006. 11(3):157–160.
https://psnet.ahrq.gov/issue/using-patient-safety-science-explore-strategies-improving-safety-intravenous-…
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psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Newspaper/Magazine Article
RaDonda Vaught says some system practices contributed to fatal mistake.
Citation Text:
RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024.
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psnet.ahrq.gov/issue/influencing-leadership-perceptions-patient-safety-through-just-culture-training
September 24, 2010 - Commentary
Influencing leadership perceptions of patient safety through just culture training.
Citation Text:
Vogelsmeier A, Scott-Cawiezell J, Miller B, et al. Influencing leadership perceptions of patient safety through just culture training. J Nurs Care Qual. 2010;25(4):288-94. doi:…
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psnet.ahrq.gov/issue/establishing-culture-patient-safety-role-education
August 23, 2017 - Commentary
Establishing a culture for patient safety - the role of education.
Citation Text:
Milligan FJ. Establishing a culture for patient safety - the role of education. Nurse Educ Today. 2007;27(2):95-102.
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psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm
January 27, 2021 - Newspaper/Magazine Article
Pump up the volume: tips for increasing error reporting and decreasing patient harm.
Citation Text:
Pump up the volume: tips for increasing error reporting and decreasing patient harm. ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5…
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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/iatrogenic-events-neonates-beneficial-effects-prevention-strategies-and-continuous-monitoring
February 20, 2008 - Study
Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring.
Citation Text:
Ligi I, Millet V, Sartor C, et al. Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. Pediatrics. 2010;126(6):e146…
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psnet.ahrq.gov/issue/defensive-medicine-among-high-risk-specialist-physicians-volatile-malpractice-environment
February 17, 2011 - Study
Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.
Citation Text:
Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609-17.
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psnet.ahrq.gov/issue/unreported-errors-intensive-care-unit-case-study-way-we-work
December 12, 2012 - Commentary
Unreported errors in the intensive care unit: a case study of the way we work.
Citation Text:
Henneman EA. Unreported errors in the intensive care unit: a case study of the way we work. Crit Care Nurse. 2007;27(5):27-34; quiz 35.
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psnet.ahrq.gov/issue/importance-establishing-regimen-concordance-preventing-medication-errors-anticoagulant-care
January 02, 2017 - Study
The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.
Citation Text:
Schillinger D, Wang F, Rodriguez M, et al. The importance of establishing regimen concordance in preventing medication errors in anticoagulant care. J Health C…
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psnet.ahrq.gov/issue/death-handwriting
October 19, 2022 - Newspaper/Magazine Article
Death by handwriting.
Citation Text:
Glabman M. Death by handwriting. Trustee : the journal for hospital governing boards. 2005;58(9):29-32.
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psnet.ahrq.gov/issue/malpractice-reform-opportunities-leadership-health-care-institutions-and-liability-insurers
December 19, 2018 - Commentary
Malpractice reform—opportunities for leadership by health care institutions and liability insurers.
Citation Text:
Mello MM, Gallagher TH. Malpractice reform--opportunities for leadership by health care institutions and liability insurers. N Engl J Med. 2010;362(15):1353-6. …
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psnet.ahrq.gov/issue/testing-classification-model-emergency-department-errors
March 02, 2010 - Study
Testing a classification model for emergency department errors.
Citation Text:
Henneman EA, Blank FSJ, Gattasso S, et al. Testing a classification model for emergency department errors. J Adv Nurs. 2006;55(1):90-9.
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psnet.ahrq.gov/issue/mistakes-and-disclosure
October 19, 2022 - Commentary
Mistakes and disclosure.
Citation Text:
Winter RO, Birnberg BA. Mistakes and disclosure. Fam Med. 2008;40(4):245-7.
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psnet.ahrq.gov/issue/changing-course
March 26, 2014 - Newspaper/Magazine Article
Changing course.
Citation Text:
DerGurahian J. Changing course. A few well-publicized cases of medical errors have led the hospitals involved to transform how they approach patient safety. Modern healthcare. 2009;39(44):6-7, 16, 1.
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psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low-dose-alerts
November 18, 2020 - Newspaper/Magazine Article
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?
Citation Text:
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? ISMP Medication Safety Alert! Acute Care Edition. …