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psnet.ahrq.gov/node/846167/psn-pdf
March 15, 2023 - Diagnostic stewardship to prevent diagnostic error.
March 15, 2023
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA.
2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
The effective use of resour…
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psnet.ahrq.gov/node/845352/psn-pdf
September 06, 2023 - Understanding and Improving Diagnostic Safety in
Ambulatory Care.
September 6, 2023
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
https://psnet.ahrq.gov/issue/understanding-and-improving-diagnostic-safety-ambulatory-care
The articulation of diagnostic error in the ambulatory setting i…
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psnet.ahrq.gov/node/38211/psn-pdf
May 21, 2009 - Effectiveness of a barcode medication administration
system in reducing preventable adverse drug events in a
neonatal intensive care unit: a prospective cohort study.
May 21, 2009
Morriss FH, Abramowitz PW, Nelson S, et al. Effectiveness of a barcode medication administration system
in reducing preventable adverse…
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psnet.ahrq.gov/node/46136/psn-pdf
September 27, 2017 - Medication errors in injured patients.
September 27, 2017
Dolejs SC, Janowak CF, Zarzaur BL. Medication Errors in Injured Patients. Am Surg. 2017;83(7):780-785.
https://psnet.ahrq.gov/issue/medication-errors-injured-patients
Despite the widespread adoption of health information technology, medication errors remain …
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psnet.ahrq.gov/node/38838/psn-pdf
May 25, 2010 - Multidisciplinary system for detecting medication errors
in antineoplastic chemotherapy.
May 25, 2010
Serrano-Fabiá A, Albert-Marí A, Almenar-Cubells D, et al. Multidisciplinary system for detecting medication
errors in antineoplastic chemotherapy. J Oncol Pharm Pract. 2010;16(2):105-12.
doi:10.1177/10781552093404…
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psnet.ahrq.gov/node/838929/psn-pdf
October 26, 2022 - Toolkit To Improve Antibiotic Use in Ambulatory Care.
October 26, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit a…
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psnet.ahrq.gov/node/36711/psn-pdf
July 25, 2011 - Designing decision support for insulin ordering in a
computerized provider order entry system.
July 25, 2011
Wright L, Feldott CC, Hargrove FR. Designing Decision Support for Insulin Ordering in a Computerized
Provider Order Entry System. Hosp Pharm. 2010;42(2). doi:10.1310/hpj4202-158.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/41436/psn-pdf
October 19, 2012 - Which clinical errors lead to the referral of UK
paediatricians to the National Clinical Assessment
Service?
October 19, 2012
Raine J, Scarrott D. Which clinical errors lead to the referral of UK paediatricians to the National Clinical
Assessment Service? Eur J Pediatr. 2012;171(10):1449-52.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/43700/psn-pdf
November 19, 2014 - Appropriate use of medical interpreters.
November 19, 2014
Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-80.
https://psnet.ahrq.gov/issue/appropriate-use-medical-interpreters
Language barriers between patients and providers can contribute to misunderstandings and lead…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/73885/psn-pdf
September 29, 2021 - Reporting of unsafe conditions at an academic women
and children's hospital.
September 29, 2021
Grabinski ZG, Babineau J, Jamal N, et al. Reporting of unsafe conditions at an academic women and
children's hospital. Jt Comm J Qual Patient Saf. 2021;47(11):731-738. doi:10.1016/j.jcjq.2021.08.004.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43229/psn-pdf
June 04, 2014 - Liquid medication dosing errors in children: role of
provider counseling strategies.
June 4, 2014
Yin S, Dreyer BP, Moreira HA, et al. Liquid medication dosing errors in children: role of provider counseling
strategies. Acad Pediatr. 2014;14(3):262-70. doi:10.1016/j.acap.2014.01.003.
https://psnet.ahrq.gov/issue/l…
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Research from webAIRS incident reporting system.
November 29, 2023
Anaesth Intensive Care. 2023;51(6):372-421.
https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
Centralized de-identified reports of patient safety events serve a core purpose for learning and
improvement. This article collectio…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-figures1-2.pdf
April 21, 2015 - Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Figures 1 & 2
Figure 1
Figure 2
From: American College of Radiology Expert Panel on Pediatric Imaging: Hayes LL, Coley BD, Karmazyn B, et al. ACR
Appropriateness Criteria: Headache — child. American College of…
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psnet.ahrq.gov/node/45930/psn-pdf
April 26, 2017 - A boy's life is lost to sepsis. Thousands are saved in his
wake.
April 26, 2017
Dwyer J. New York Times. April 13, 2017.
https://psnet.ahrq.gov/issue/boys-life-lost-sepsis-thousands-are-saved-his-wake
Stories of patient harm due to medical mistakes can serve as catalysts for organizational improvement.
This newsp…
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psnet.ahrq.gov/node/35106/psn-pdf
April 06, 2011 - A case of the birth and death of a high reliability
healthcare organisation.
April 6, 2011
Roberts KH, Madsen P, Desai V, et al. A case of the birth and death of a high reliability healthcare
organisation. Qual Saf Health Care. 2005;14(3):216-20.
https://psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-h…
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psnet.ahrq.gov/node/38803/psn-pdf
December 14, 2016 - Improving patient safety: effects of a safety program on
performance and culture in a department of radiology.
December 14, 2016
Donnelly LF, Dickerson JM, Goodfriend MA, et al. Improving patient safety: effects of a safety program on
performance and culture in a department of radiology. AJR Am J Roentgenol. 2009;1…
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psnet.ahrq.gov/node/45572/psn-pdf
March 22, 2017 - Ordering interruptions in a tertiary care center: a
prospective observational study.
March 22, 2017
Dadlez NM, Azzarone G, Sinnett MJ, et al. Ordering Interruptions in a Tertiary Care Center: A Prospective
Observational Study. Hosp Pediatr. 2017;7(3):134-139. doi:10.1542/hpeds.2016-0127.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41738/psn-pdf
June 10, 2018 - Inappropriate use of pharmacy bulk packages of IV
contrast media increases risk of infections.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4.
https://psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk-
infections
This articl…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/health-it-survey-compendium/clinical-decision
January 01, 2023 - Clinical Decision Support System Satisfaction Survey
This is a questionnaire designed to be completed by clinical and office staff in a pediatric setting. The tool includes questions to assess staff attitudes and assessment of a clinical decision support tool.
Survey Document
Clinical Decision…