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psnet.ahrq.gov/issue/understanding-principles-high-reliability-organizations-through-eyes-vione-clinical-program
November 15, 2023 - Study
Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy.
Citation Text:
Battar S, Dickerson KRW, Sedgwick C, et al. Understand…
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psnet.ahrq.gov/issue/role-ai-detecting-and-mitigating-human-errors-safety-critical-industries-review
January 15, 2025 - Review
The role of AI in detecting and mitigating human errors in safety-critical industries: a review.
Citation Text:
Gursel E, Madadi M, Coble JB, et al. The role of AI in detecting and mitigating human errors in safety-critical industries: a review. Reliability Eng System Saf. 2025;25…
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psnet.ahrq.gov/issue/review-medication-errors-are-new-or-likely-occur-more-frequently-electronic-medication
August 18, 2021 - Study
Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.
Citation Text:
Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medicatio…
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psnet.ahrq.gov/issue/not-another-safety-culture-survey-using-canadian-patient-safety-climate-survey-can-pscs
February 14, 2015 - Study
'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.
Citation Text:
Ginsburg LR, Tregunno D, Norton PG, et al. 'Not another safety culture survey': using the Canadian patien…
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psnet.ahrq.gov/issue/incidence-and-severity-medication-reconciliation-discrepancies-trauma-patients
October 19, 2022 - Study
Incidence and severity of medication reconciliation discrepancies in trauma patients.
Citation Text:
Dunbar EG, Massey AC, Lee YL, et al. Incidence and severity of medication reconciliation discrepancies in trauma patients. Am Surg. 2023;89(7):3272-3274. doi:10.1177/000313482311616…
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psnet.ahrq.gov/issue/development-proactive-process-harmonize-policy-infusion-pump-library-and-electronic-health
October 19, 2022 - Study
Development of a proactive process to harmonize policy, infusion pump library, and electronic health record entries for continuous infusions at an academic medical center.
Citation Text:
Christensen SM, Andrews SR, Fox ER. Development of a proactive process to harmonize policy, inf…
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psnet.ahrq.gov/node/35744/psn-pdf
July 15, 2010 - Medication safety infrastructure in critical-access
hospitals in Florida.
July 15, 2010
Winterstein AG, Hartzema AG, Johns TE, et al. Medication safety infrastructure in critical-access hospitals
in Florida. American Journal of Health-System Pharmacy. 2006;63(5). doi:10.2146/ajhp050345.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/40557/psn-pdf
June 29, 2011 - A systemic methodology for risk management in
healthcare sector.
June 29, 2011
Cagliano AC, Grimaldi S, Rafele C. A systemic methodology for risk management in healthcare sector. Saf
Sci. 2011;49(5). doi:10.1016/j.ssci.2011.01.006.
https://psnet.ahrq.gov/issue/systemic-methodology-risk-management-healthcare-sector…
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psnet.ahrq.gov/node/38360/psn-pdf
March 18, 2010 - Medication errors occurring with the use of bar-code
administration technology.
March 18, 2010
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology
This article describes errors associated with bar coded medication admin…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/org_embrace-slides/Organizational-Embrace-of-CUSP-to-Improve-Patient-Safety-Mar-20-2012-508.ppt
January 01, 2012 - Slide 1
CLABSI Supplemental Call Series
The Organizational Embrace
of CUSP to Improve Patient Safety
March 20, 2012
*
Objectives
To relate an organization’s approach to implementing CUSP in multiple areas of the hospital to reduce harm beyond CLABSI and CAUTI and to improve the overall culture of safety
To…
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www.ahrq.gov/research/shuttered/acfselection/appendixd.html
July 01, 2018 - its own pharmacy and central supply
All medications were initially filled by off-site [hospital] pharmacies … (pharma)
Local pharmacies. Samples from doctors.
.
Other Pediatrics Supplies?
Yes
.
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psnet.ahrq.gov/node/35298/psn-pdf
August 08, 2018 - Safety still compromised by computer weaknesses.
August 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3.
https://psnet.ahrq.gov/issue/safety-still-compromised-computer-weaknesses
The Institute for Safe Medication Practices (ISMP) reports on a 2005 field test that indicates many
pha…
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psnet.ahrq.gov/node/41345/psn-pdf
September 08, 2016 - A shortage of everything except errors: harm associated
with drug shortages.
September 8, 2016
ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.
https://psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
This article reports results from a survey of hospita…
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psnet.ahrq.gov/node/40830/psn-pdf
October 05, 2011 - "Tech-check-tech": a review of the evidence on its safety
and benefits.
October 5, 2011
Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": a review of the evidence on its safety and benefits.
Am J Health Syst Pharm. 2011;68(19):1824-33. doi:10.2146/ajhp110022.
https://psnet.ahrq.gov/issue/tech-check-tech-review-ev…
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digital.ahrq.gov/organization/childrens-healthcare-atlanta-inc
January 01, 2023 - Children's Healthcare of Atlanta, Inc.
Comprehensive Information Technology (IT) Solution for Quality and Patient Safety - 2009
Principal Investigator
Jose, Jim
Project Name
Comprehensive Information Technology (IT) Solution for Quality and Patient Safety
…
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digital.ahrq.gov/ahrq-funded-projects/medicaid-and-chip/malone-dc-saverno-kr-2012-evaluation-wireless-handheld
January 01, 2012 - Malone DC, Saverno, KR. (2012). Evaluation of a wireless handheld medication management device in the prevention of drug-drug interactions in a Medicaid population. J Manag Care Pharm 2012;18(1):33-45.
www.amcp.org Vol. 18, No. 1 January/February 2012 JMCP Journal of Managed Care Pharmacy 33 • Medication …
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psnet.ahrq.gov/node/39519/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest
Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order
by Metric Weight, Not Volume. Hosp Pharm. 2010;45(4). doi:10.1310/hpj45…
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psnet.ahrq.gov/node/40655/psn-pdf
September 12, 2016 - Impact of drug shortages on U.S. health systems.
September 12, 2016
Kaakeh R, Sweet B, Reilly C, et al. Impact of drug shortages on U.S. health systems. Am J Health Syst
Pharm. 2011;68(19):1811-9. doi:10.2146/ajhp110210.
https://psnet.ahrq.gov/issue/impact-drug-shortages-us-health-systems
This study surveyed pharm…
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psnet.ahrq.gov/node/50582/psn-pdf
October 23, 2019 - Medication errors: the year in review.
October 23, 2019
Valentine D, Ingram V, Fobi B et al. Pharmacy Practice News. September 10, 2019.
https://psnet.ahrq.gov/issue/medication-errors-year-review
Medication error prevention is an evolving goal for health care. This article discusses distinct medications
and errors…
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psnet.ahrq.gov/node/41673/psn-pdf
September 12, 2012 - A root cause analysis project in a medication safety
course.
September 12, 2012
Schafer JJ. A root cause analysis project in a medication safety course. Am J Pharm Educ.
2012;76(6):116. doi:10.5688/ajpe766116.
https://psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course
This commentary descri…