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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…
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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include incidents…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/redtoolkitforms.pdf
September 01, 2012 - Yes ____ No ____
Community Pharmacy Name Phone #, Street Address, City
Pt. plan to pick
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psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid
February 16, 2022 - Related Resources From the Same Author(s)
Mapping the resilience performance of community … pharmacy to maintain patient safety during the Covid-19 pandemic.
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psnet.ahrq.gov/issue/crisis-management-surgical-teams-and-their-leaders-lessons-covid-19-pandemic-structured
February 12, 2020 - March 17, 2021
Mapping the resilience performance of community pharmacy to maintain patient
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www.ahrq.gov/data/resources/index.html?page=4
Surveys on Patient Safety Culture™ (SOPS™): Community Pharmacy Database
AHRQ established the Surveys
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psnet.ahrq.gov/issue/alternative-strategy-studying-adverse-events-medical-care
June 03, 2020 - November 26, 2014
Communicating medication changes to community pharmacy post-discharge
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014882-ferranti-final-report-2008.pdf
January 01, 2008 - Automated Adverse Drug Event Detection and Intervention - Final Report
‡
* Duke University Health System ‡ Duke Durham Regional Hospital
† Duke University Hospital § Duke Raleigh Hospital
Grant Final Repor…
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www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
January 01, 2024 - Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2)
1 | P a g e
Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2)
Principal Investigator: Jeffrey L. Schnipper, MD, MPH
Team Members: Harry Reyes Nieva, MAS; Me…
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www.ahrq.gov/sites/default/files/2024-11/wakefield2-report.pdf
January 01, 2024 - Final Progress Report: Verbal Order Policies, Occurrence, and Perceptions
Verbal Order Policies, Occurrence, and Perceptions
Douglas S. Wakefield, PhD
Principal Investigator
Center for Health Care Quality
University of Missouri
Bonnie Wakefield, RN, PhD
Co-Investigator
Associate Research Professor
Sinclair…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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digital.ahrq.gov/ahrq-funded-projects/electronic-health-record-implementation-continuum-care-rural-iowa
January 01, 2023 - Electronic Health Record Implementation for Continuum of Care in Rural Iowa
Project Final Report ( PDF , 333.71 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily repres…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-177-section-2-technical-specs.pdf
May 23, 2014 - National Collaborative for Innovation in Quality Measurement
National Collaborative for Innovation in Quality Measurement
Administrative Sp…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - Pharmacies should dispense liquid medications that come in bulk bottles in unit-dose cups or oral syringes
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - By standardizing
concentrations of high alert medications, hospital pharmacies can provide ready-to-use