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psnet.ahrq.gov/node/40565/psn-pdf
June 29, 2011 - National study on the frequency, types, causes, and
consequences of voluntarily reported emergency
department medication errors.
June 29, 2011
Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of
voluntarily reported emergency department medication errors. J Emerg…
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psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - Patient safety culture, health information technology
implementation, and medical office problems that could
lead to diagnostic error.
October 3, 2018
Campione JR, Mardon RE, McDonald KM. Patient Safety Culture, Health Information Technology
Implementation, and Medical Office Problems That Could Lead to Diagnostic…
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psnet.ahrq.gov/issue/costs-intravenous-adverse-drug-events-academic-and-nonacademic-intensive-care-units
August 11, 2021 - Study
Costs of intravenous adverse drug events in academic and nonacademic intensive care units.
Citation Text:
Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous adverse drug events in academic and nonacademic intensive care units. Med Care. 2009;46(1):17-24. doi:10.1097/m…
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psnet.ahrq.gov/issue/disentangling-quality-and-safety-indicator-data-longitudinal-comparative-study-hand-hygiene
March 23, 2011 - Study
Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals.
Citation Text:
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudi…
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psnet.ahrq.gov/issue/pharmacist-physician-communications-highly-computerised-hospital-sign-and-action-electronic
February 27, 2019 - Study
Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.
Citation Text:
Pontefract SK, Hodson J, Marriott JF, et al. Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electr…
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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Sch…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/35892/psn-pdf
July 23, 2010 - Medical errors: should you apologize?
July 23, 2010
Weiss GG. Medical errors. Should you apologize? Medical economics. 2006;83(8):50-4.
https://psnet.ahrq.gov/issue/medical-errors-should-you-apologize
This article discusses disclosure of adverse events from various perspectives and provides suggestions on
apologiz…
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psnet.ahrq.gov/node/35153/psn-pdf
June 19, 2009 - Managing medication errors—a qualitative study.
June 19, 2009
Stetina P, Groves M, Pafford L. Managing medication errors--a qualitative study. Medsurg Nurs.
2005;14(3):174-8.
https://psnet.ahrq.gov/issue/managing-medication-errors-qualitative-study
The authors conducted interviews with practicing nurses regarding …
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psnet.ahrq.gov/node/42615/psn-pdf
September 25, 2013 - Examining medication reconciliation from a perspective
of safety.
September 25, 2013
Daly M, Lee B. Formulary. August 8, 2013.
https://psnet.ahrq.gov/issue/examining-medication-reconciliation-perspective-safety
This article examines the value of medication reconciliation as a strategy to improve safety and reveals…
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psnet.ahrq.gov/node/60994/psn-pdf
October 07, 2020 - Potentially inappropriate medication combination with
opioids among older dental patients: a retrospective
review of insurance claims data.
October 7, 2020
Zhou J, Calip GS, Rowan S, et al. Potentially inappropriate medication combination with opioids among
older dental patients: a retrospective review of insuranc…
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psnet.ahrq.gov/node/866538/psn-pdf
August 14, 2024 - Improving departmental psychological safety through a
medical school-wide initiative
August 14, 2024
Porter-Stransky KA, Horneffer-Ginter KJ, Bauler LD, et al. Improving departmental psychological safety
through a medical school-wide initiative. BMC Med Educ. 2024;24(1):800. doi:10.1186/s12909-024-05794-
4.
https…
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psnet.ahrq.gov/node/42779/psn-pdf
January 29, 2014 - Governing patient safety: lessons learned from a mixed
methods evaluation of implementing a ward-level
medication safety scorecard in two English NHS
hospitals.
January 29, 2014
Ramsay AIG, Turner S, Cavell G, et al. Governing patient safety: lessons learned from a mixed methods
evaluation of implementing a ward-…
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psnet.ahrq.gov/node/841486/psn-pdf
January 26, 2018 - Do words matter? Stigmatizing language and the
transmission of bias in the medical record.
January 26, 2018
P. Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission
of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:10.1007/s11606-017-4289-2.
http…
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psnet.ahrq.gov/node/46683/psn-pdf
February 14, 2018 - Changing experience of adverse medical events in the
National Health Service: comparison of two population
surveys in 2001 and 2013.
February 14, 2018
Gray AM, Fenn P, Rickman N, et al. Changing experience of adverse medical events in the National Health
Service: Comparison of two population surveys in 2001 and 20…
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psnet.ahrq.gov/node/43767/psn-pdf
February 04, 2015 - Self-reported patient safety competence among Canadian
medical students and postgraduate trainees: a cross-
sectional survey.
February 4, 2015
Doyle P, VanDenKerkhof E, Edge DS, et al. Self-reported patient safety competence among Canadian
medical students and postgraduate trainees: a cross-sectional survey. BMJ Q…
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psnet.ahrq.gov/node/50753/psn-pdf
December 18, 2019 - The contribution of staffing to medication administration
errors: a text mining analysis of incident report data.
December 18, 2019
Härkänen M, Vehviläinen?Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication
Administration Errors: A Text Mining Analysis of Incident Report Data. J Nurs Scholars…
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psnet.ahrq.gov/node/47242/psn-pdf
January 01, 2021 - "It matters what I think, not what you say": scientific
evidence for a medical error disclosure competence
(MEDC) model.
October 10, 2018
Hannawa AF, Frankel RM. "It Matters What I Think, Not What You Say": Scientific Evidence for a Medical
Error Disclosure Competence (MEDC) Model. J Patient Saf. 2021;17(8):e1130-…