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  1. psnet.ahrq.gov/issue/epidemiology-prescribing-errors-potential-impact-computerized-prescriber-order-entry
    May 04, 2010 - Study The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Citation Text: Bobb A, Gleason KM, Husch M, et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7…
  2. psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors
    March 20, 2019 - Review New solutions to reduce wrong route medication errors. Citation Text: Litman RS, Smith VI, Mainland P. New solutions to reduce wrong route medication errors. Paediatr Anaesth. 2018;28(1):8-12. doi:10.1111/pan.13279. Copy Citation Format: DOI Google Scholar PubMed Bib…
  3. psnet.ahrq.gov/issue/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
    April 27, 2019 - Study Unintentionally retained guidewires: a descriptive study of 73 sentinel events. Citation Text: Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…
  4. psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
    April 27, 2019 - Study Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. Citation Text: Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
  5. psnet.ahrq.gov/issue/when-err-inhuman-examination-influence-artificial-intelligence-driven-nursing-care-patient
    October 19, 2022 - Commentary When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety. Citation Text: Johnson EA, Dudding KM, Carrington JM. When to err is inhuman: an examination of the influence of artificial intelligence‐driven nursing car…
  6. psnet.ahrq.gov/issue/detection-and-measurement-rotator-cuff-tears-sonography-analysis-diagnostic-errors
    December 31, 2014 - Study Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. Citation Text: Teefey SA, Middleton WD, Payne WT, et al. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol. 2005;184(6…
  7. psnet.ahrq.gov/issue/patient-safety-instruction-us-health-professions-education
    September 01, 2015 - Review Patient safety instruction in US health professions education. Citation Text: Kiersma ME, Plake KS, Darbishire PL. Patient safety instruction in US health professions education. Am J Pharm Educ. 2011;75(8):162. doi:10.5688/ajpe758162. Copy Citation Format: DOI Goog…
  8. psnet.ahrq.gov/issue/nursephysician-communication-through-sensemaking-lens-shifting-paradigm-improve-patient
    June 05, 2024 - Review Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Citation Text: Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Med Care. 2010;48(11):941-6. doi:10…
  9. psnet.ahrq.gov/issue/what-did-doctor-say-health-literacy-and-recall-medical-instructions
    December 21, 2014 - Study What did the doctor say? Health literacy and recall of medical instructions. Citation Text: McCarthy D, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277-82. doi:10.1097/MLR.0b013e318241e8e1. Copy C…
  10. psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-advocacy-lexington-veterans-affairs-medical-center
    March 02, 2011 - Commentary John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center. Citation Text: Kraman SS, Cranfill L, Hamm G, et al. John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002;…
  11. psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
    October 09, 2013 - Press Release/Announcement Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. Citation Text: Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. …
  12. psnet.ahrq.gov/issue/world-health-organization-5-moments-hand-hygiene-scientific-foundation
    October 19, 2022 - Commentary The World Health Organization '5 moments of hand hygiene': the scientific foundation. Citation Text: Chou DTS, Achan P, Ramachandran M. The World Health Organization '5 moments of hand hygiene': the scientific foundation. J Bone Joint Surg Br. 2012;94(4):441-5. doi:10.1302/0…
  13. psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound
    December 13, 2023 - Commentary Systematic error and cognitive bias in obstetric ultrasound. Citation Text: Sotiriadis A, Odibo AO. Systematic error and cognitive bias in obstetric ultrasound. Ultrasound Obstet Gynecol. 2019;53(4):431-435. doi:10.1002/uog.20232. Copy Citation Format: DOI Google…
  14. psnet.ahrq.gov/issue/perceptions-preventable-medical-errors-alberta-canada
    January 21, 2019 - Study Perceptions of preventable medical errors in Alberta, Canada. Citation Text: Northcott H, Vanderheyden L, Northcott J, et al. Perceptions of preventable medical errors in Alberta, Canada. Int J Qual Health Care. 2007;20(2):115-122. doi:10.1093/intqhc/mzm067. Copy Citation F…
  15. psnet.ahrq.gov/issue/inpatient-notes-just-what-doctor-ordered-checklists-improve-diagnosis
    August 14, 2019 - Commentary Inpatient notes: just what the doctor ordered—checklists to improve diagnosis. Citation Text: Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.…
  16. psnet.ahrq.gov/issue/nature-causes-and-consequences-unintended-events-surgical-units
    September 07, 2016 - Study Nature, causes and consequences of unintended events in surgical units. Citation Text: van Wagtendonk I, Smits M, Merten H, et al. Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010;97(11):1730-40. doi:10.1002/bjs.7201. Copy Citation Form…
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sbs.pdf
    June 02, 2025 - NICU Family Information Packet, Appendix B, Short Bowel Syndrome Short Bowel Syndrome Pathophysiology ■ Functional disorder caused by alterations of normal intestinal anatomy and physiology. ■ Shortened bowel combined with malabsorption; dependent on parenteral nutrition >3 months. ■ May result from: necrotizin…
  18. psnet.ahrq.gov/issue/relationship-incorrect-dosing-fibrinolytic-therapy-and-clinical-outcomes
    November 10, 2015 - Study Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. Citation Text: Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA. 2005;293(14). doi:10.1001/jama.293.14.1746. Copy Citation Format: DOI Googl…
  19. psnet.ahrq.gov/issue/shifting-learning-curve
    March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  20. psnet.ahrq.gov/issue/admission-handoff-communications-clinicians-shared-understanding-patient-severity-illness-and
    May 31, 2017 - Study Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. Citation Text: Brannen M, Cameron KA, Adler MD, et al. Admission Handoff Communications. J Patient Saf. 2009;5(4). doi:10.1097/pts.0b013e3181c029e5. Copy Citation …