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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/prevalence-adverse-drug-combinations-large-post-mortem-toxicology-database
July 29, 2020 - Study
Prevalence of adverse drug combinations in a large post-mortem toxicology database.
Citation Text:
Launiainen T, Vuori E, Ojanperä I. Prevalence of adverse drug combinations in a large post-mortem toxicology database. Int J Legal Med. 2009;123(2):109-15. doi:10.1007/s00414-008-02…
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psnet.ahrq.gov/issue/mcneil-consumer-specialty-pharmaceuticals-announces-nationwide-recall-childrens-tylenol
August 19, 2020 - Press Release/Announcement
McNeil Consumer & Specialty Pharmaceuticals announces nationwide recall of Children's Tylenol Meltaways - 80 Mg, Children's Tylenol Softchews - 80 Mg and Jr. Tylenol Meltaways - 160 Mg [press release].
Citation Text:
McNeil Consumer & Specialty Pharmaceuticals…
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psnet.ahrq.gov/issue/verbal-medication-orders-or
March 06, 2024 - Commentary
Verbal medication orders in the OR.
Citation Text:
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
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psnet.ahrq.gov/issue/covid-19-focused-inspection-initiative-healthcare
April 01, 2024 - Press Release/Announcement
COVID-19 Focused Inspection Initiative in Healthcare.
Citation Text:
COVID-19 Focused Inspection Initiative in Healthcare. Occupational Safety and Health Administration. March 2, 2022.
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psnet.ahrq.gov/issue/medication-safety-issue-brief-look-alike-sound-alike-drugs
June 17, 2014 - Newspaper/Magazine Article
Medication safety issue brief. Look-alike, sound-alike drugs.
Citation Text:
Association AH, Pharmacists AS of H-S, Networks H & H. Medication safety issue brief, look-alike, sound-alike drugs. Hospitals and Health Networks. October 2005;79(10):57-58.
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psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-overdose-induction-general-anesthesia
March 17, 2021 - Commentary
Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia.
Citation Text:
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case Rep. 2018;19:10-12.
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psnet.ahrq.gov/issue/respectful-trusting-relationships-are-essential-patient-safety-especially-surgeon
December 08, 2024 - Meeting/Conference Proceedings
Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad.
Citation Text:
Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad. Cooper J. An…
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psnet.ahrq.gov/issue/ashp-guidelines-safe-use-automated-dispensing-devices
July 05, 2017 - Organizational Policy/Guidelines
ASHP guidelines on the safe use of automated dispensing devices.
Citation Text:
Cello R, Conley M, Cooley TW, et al. ASHP Guidelines on the Safe Use of Automated Dispensing Cabinets. Am J Health Syst Pharm. 2021;79(1):e71-e82. doi:10.1093/ajhp/zxab325. …
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psnet.ahrq.gov/issue/performing-inadvertent-procedure
October 16, 2019 - Commentary
Performing an inadvertent procedure.
Citation Text:
Gupta A, Jain S, Croft C. Performing an Inadvertent Procedure. JAMA. 2019;321(5):504-505. doi:10.1001/jama.2018.21438.
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psnet.ahrq.gov/issue/negotiating-safety-when-staffing-falls-short
October 19, 2022 - Commentary
Negotiating safety when staffing falls short.
Citation Text:
Zolnierek CD, Steckel CM. Negotiating Safety when Staffing Falls Short. Crit Care Nurs Clin North Am. 2010;22(2). doi:10.1016/j.ccell.2010.03.014.
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psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
November 16, 2022 - Study
Listen carefully: the risk of error in spoken medication orders.
Citation Text:
Lambert BL, Dickey LW, Fisher WM, et al. Listen carefully: the risk of error in spoken medication orders. Soc Sci Med. 2010;70(10):1599-608. doi:10.1016/j.socscimed.2010.01.042.
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psnet.ahrq.gov/issue/sample-sample-carryover-source-analytical-laboratory-error-and-its-relevance-integrated
January 12, 2022 - Study
Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.
Citation Text:
Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its relevance to integra…
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psnet.ahrq.gov/issue/high-reliability-organizations-hros-what-they-know-we-dont-part-ii
June 10, 2018 - Newspaper/Magazine Article
High-reliability organizations (HROs): what they know that we don't (Part II).
Citation Text:
High-reliability organizations (HROs): what they know that we don't (Part II). ISMP Medication Safety Alert! Acute Care Edition. July 28, 2005;10:1-3.
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psnet.ahrq.gov/issue/when-should-leader-apologize-and-when-not
October 07, 2020 - Commentary
When should a leader apologize—and when not?
Citation Text:
Kellerman B. When should a leader apologize and when not? Harv Bus Rev. 2006;84(4):72-81; 148.
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psnet.ahrq.gov/issue/radically-redesigning-patient-safety
November 13, 2024 - Newspaper/Magazine Article
Radically redesigning patient safety.
Citation Text:
Radick LE. Radically Redesigning Patient Safety. Healthcare executive. 2016;31(2):32-4, 36-40, 42.
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psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
March 14, 2023 - Newspaper/Magazine Article
Implement strategies to prevent persistent medication errors and hazards.
Citation Text:
Implement strategies to prevent persistent medication errors and hazards. ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
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psnet.ahrq.gov/issue/simple-strategies-avoid-medication-errors
April 22, 2017 - Commentary
Simple strategies to avoid medication errors.
Citation Text:
Jenkins RH, Vaida AJ. Simple strategies to avoid medication errors. Fam Pract Manag. 2007;14(2):41-47.
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psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
November 28, 2018 - Commentary
An organizational learning framework for patient safety.
Citation Text:
Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-155. doi:10.1177/1062860616632295.
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psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
November 30, 2016 - Newspaper/Magazine Article
Preventing errors when preparing and administering medications via enteral feeding tubes.
Citation Text:
Preventing errors when preparing and administering medications via enteral feeding tubes. ISMP Medication Safety Alert! Acute care edition. November 17, 202…