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psnet.ahrq.gov/node/45717/psn-pdf
July 21, 2017 - What have we learnt after 15 years of research into the
'weekend effect'?
July 21, 2017
Bray BD, Steventon A. What have we learnt after 15 years of research into the 'weekend effect'? BMJ Qual
Saf. 2017;26(8):607-610. doi:10.1136/bmjqs-2016-005793.
https://psnet.ahrq.gov/issue/what-have-we-learnt-after-15-years-re…
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - Alarm fatigue: impacts on patient safety.
December 16, 2015
Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol.
2015;28(6):685-690. doi:10.1097/ACO.0000000000000260.
https://psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety
Alarm fatigue is a recognized safety conce…
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psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors.
July 23, 2014
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs
Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
Thi…
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psnet.ahrq.gov/node/40530/psn-pdf
September 25, 2011 - Patient safety factors in children dying in a paediatric
intensive care unit (PICU): a case notes review study.
September 25, 2011
Monroe K, Wang D, Vincent CA, et al. Patient safety factors in children dying in a paediatric intensive care
unit (PICU): a case notes review study. BMJ Qual Saf. 2011;20(10):863-8.
do…
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psnet.ahrq.gov/node/43284/psn-pdf
November 28, 2016 - Parental involvement in the preoperative surgical safety
checklist is welcomed by both parents and staff.
November 28, 2016
Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by
both parents and staff. Int J Pediatr. 2014;2014:791490. doi:10.1155/2014/791490.
htt…
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psnet.ahrq.gov/node/41193/psn-pdf
August 02, 2012 - Medicaid, hospital financial stress, and the incidence of
adverse medical events for children.
August 2, 2012
Smith RB, Dynan L, Fairbrother G, et al. Medicaid, hospital financial stress, and the incidence of adverse
medical events for children. Health Serv Res. 2012;47(4):1621-41. doi:10.1111/j.1475-6773.2012.0138…
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psnet.ahrq.gov/node/47824/psn-pdf
May 20, 2019 - Exploring the human factors of prescribing errors in
paediatric intensive care units.
May 20, 2019
Sutherland A, Ashcroft DM, Phipps D. Exploring the human factors of prescribing errors in paediatric
intensive care units. Arch Dis Child. 2019;104(6):588-595. doi:10.1136/archdischild-2018-315981.
https://psnet.ahrq…
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psnet.ahrq.gov/node/44989/psn-pdf
July 01, 2016 - Can medical record reviewers reliably identify errors and
adverse events in the ED?
July 1, 2016
Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse
events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.001.
https://psnet.ahrq.gov/issue/can…
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psnet.ahrq.gov/node/45281/psn-pdf
September 01, 2016 - Screen flashes and pop-up reminders: 'alert fatigue'
spreads through medicine.
September 1, 2016
Luthra S. Kaiser Health News. June 15, 2016.
https://psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine
Alert fatigue is known to contribute to medical error. This news article…
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psnet.ahrq.gov/node/38804/psn-pdf
July 22, 2009 - Tenfold therapeutic dosing errors in young children
reported to US poison control centers.
July 22, 2009
Crouch BI, Caravati M, Moltz E. Tenfold therapeutic dosing errors in young children reported to U.S. poison
control centers. Am J Health Syst Pharm. 2009;66(14):1292-6. doi:10.2146/080377.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47122/psn-pdf
June 13, 2018 - Intravenous chemotherapy compounding errors in a
follow-up pan-Canadian observational study.
June 13, 2018
Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up
Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007.
https://psne…
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psnet.ahrq.gov/node/74046/psn-pdf
January 01, 2022 - Racial disparities in child abuse medicine.
November 3, 2021
Rosenthal CM, Parker DM, Thompson LA. Racial disparities in child abuse medicine. JAMA Pediatr.
2022;176(2):119-120. doi:10.1001/jamapediatrics.2021.3601.
https://psnet.ahrq.gov/issue/racial-disparities-child-abuse-medicine
The care of child abuse victim…
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psnet.ahrq.gov/node/45423/psn-pdf
September 27, 2016 - Lost in translation: impact of language barriers on
children's healthcare.
September 27, 2016
Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr.
2016;28(5):659-666. doi:10.1097/MOP.0000000000000404.
https://psnet.ahrq.gov/issue/lost-translation-impact-language-…
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psnet.ahrq.gov/node/38777/psn-pdf
March 04, 2011 - Perceptions of standards-based electronic prescribing
systems as implemented in outpatient primary care: a
physician survey.
March 4, 2011
Wang J, Patel MH, Schueth AJ, et al. Perceptions of standards-based electronic prescribing systems as
implemented in outpatient primary care: a physician survey. J Am Med Infor…
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psnet.ahrq.gov/node/72659/psn-pdf
January 20, 2021 - Association between paediatric intraoperative
anaesthesia handover and adverse postoperative
outcomes.
January 20, 2021
Kannampallil TG, Lew D, Pfeifer EE, et al. Association between paediatric intraoperative anaesthesia
handover and adverse postoperative outcomes. BMJ Qual Saf. 2021;30(9):755-763. doi:10.1136/bmj…
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psnet.ahrq.gov/node/34730/psn-pdf
October 29, 2013 - Medication Errors. 2nd ed.
October 29, 2013
Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
https://psnet.ahrq.gov/issue/medication-errors-2nd-ed
Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of
experience as a leader in medication safety wi…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-141-written-statement.pdf
June 02, 2025 - Written Statement
To Whom It May Concern:
As one of the creators of the Pediatric Medical Complexity Algorithm (PMCA), I guarantee that
should the U.S. Department ofHealth and Human Services accept PMCA for the 2014 and/or
2015 Improved Core Measure Sets, full measure specifications for PMCA will be subject to
p…
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psnet.ahrq.gov/node/44888/psn-pdf
April 06, 2016 - Transforming the morbidity and mortality conference to
promote safety and quality in a PICU.
April 6, 2016
Cifra CL, Bembea MM, Fackler JC, et al. Transforming the morbidity and mortality conference to promote
safety and quality in a PICU. Crit Care Med. 2016;17(1):58-66. doi:10.1097/PCC.0000000000000539.
https://…
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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/46909/psn-pdf
August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working
Party.
August 1, 2018
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party
Lack of appropriate staffing can diminish the safety and effectiveness of medical service…