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psnet.ahrq.gov/issue/prevalence-study-errors-opioid-prescribing-large-teaching-hospital
October 19, 2022 - Study
A prevalence study of errors in opioid prescribing in a large teaching hospital.
Citation Text:
Davies D, Schneider F, Childs S, et al. A prevalence study of errors in opioid prescribing in a large teaching hospital. Int J Clin Pract. 2011;65(9):923-9. doi:10.1111/j.1742-1241.201…
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psnet.ahrq.gov/issue/do-no-harm-and-most-good-ai-health-care
March 19, 2019 - Commentary
To do no harm - and the most good - with AI in health care.
Citation Text:
Goldberg CB, Adams L, Blumenthal D, et al. To do no harm - and the most good - with AI in health care. NEJM AI. 2024;1(3). doi:10.1056/aip2400036.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-investment
October 29, 2017 - Study
Intravenous infusion safety technology: return on investment.
Citation Text:
Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680.
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DOI Google Scho…
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psnet.ahrq.gov/issue/pharmacist-medication-assessments-surgical-preadmission-clinic
October 15, 2008 - Study
Pharmacist medication assessments in a surgical preadmission clinic.
Citation Text:
Kwan Y, Fernandes O, Nagge JJ, et al. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med. 2007;167(10):1034-40.
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psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
October 03, 2012 - Commentary
Improving patient care. The cognitive psychology of missed diagnoses.
Citation Text:
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120.
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Google Scholar PubMed BibTeX End…
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psnet.ahrq.gov/issue/improving-medication-administration-safety-community-hospital-setting-using-lean-methodology
September 23, 2020 - Commentary
Improving medication administration safety in a community hospital setting using Lean methodology.
Citation Text:
Critchley S. Improving medication administration safety in a community hospital setting using Lean methodology. J Nurs Care Qual. 2015;30(4):345-351. doi:10.1097/N…
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psnet.ahrq.gov/issue/rapid-response-systems-patient-safety-strategy-systematic-review
March 20, 2013 - Review
Rapid response systems as a patient safety strategy: a systematic review.
Citation Text:
Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051…
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psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure
August 02, 2023 - Newspaper/Magazine Article
Mask shortage straps pharmacists who need them to keep medicines pure.
Citation Text:
Mask shortage straps pharmacists who need them to keep medicines pure. Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020.
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psnet.ahrq.gov/issue/inappropriate-surgeries-resulting-misdiagnosis-early-amyotrophic-lateral-sclerosis
October 31, 2014 - Study
Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis.
Citation Text:
Srinivasan J, Scala S, Jones R, et al. Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis. Muscle Nerve. 2006;34(3):359-60.
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psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
May 22, 2019 - Organizational Policy/Guidelines
Principles of pediatric patient safety: reducing harm due to medical care.
Citation Text:
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542…
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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psnet.ahrq.gov/issue/strategies-developing-and-recognizing-faculty-working-quality-improvement-and-patient-safety
June 28, 2023 - Commentary
Strategies for developing and recognizing faculty working in quality improvement and patient safety.
Citation Text:
Coleman DL, Wardrop RM, Levinson WS, et al. Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety. Acad Med. 2017;9…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Commission issued its 1998 Sentinel Alert about keeping concentrated potassium chloride only in hospital pharmacies … ( 11 ) found that delays in receiving dilute solutions from the pharmacy turned ICUs into de facto pharmacies