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psnet.ahrq.gov/issue/sudden-death-lung-embolism-after-inadvertent-infusion-zinc-oxide-shake-lotion
January 12, 2022 - Commentary
A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion.
Citation Text:
Pragst F, Correns A, Priem F, et al. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Forensic Sci Int. 2007;170(2-3):207-12.
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psnet.ahrq.gov/issue/influence-tall-man-lettering-errors-visual-perception-recognition-written-drug-names
December 19, 2017 - Study
The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.
Citation Text:
Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. Ergono…
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psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-labels-simulation-study
January 14, 2009 - Study
Drug selection errors in relation to medication labels: a simulation study.
Citation Text:
Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a simulation study. Anaesthesia. 2007;62(11):1090-4.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medication-mgmt-common-barriers-card-4x6.pdf
June 02, 2025 - Medication Management: Common Barriers to Medication Adherence
Common Barriers to
Medication Adherence
What Patients Might Say Possible Solutions
My medicine makes me
feel sick.
Prescribe a substitute
medication; change the dose.
I feel fine. Explain how the patient’s
disease affects the body.
I forget.
F…
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psnet.ahrq.gov/issue/generative-artificial-intelligence-patient-safety-and-healthcare-quality-review
November 16, 2022 - Review
Generative artificial intelligence, patient safety and healthcare quality: a review.
Citation Text:
Howell MD. Generative artificial intelligence, patient safety and healthcare quality: a review. BMJ Qual Saf. 2024;33(11):748-754. doi:10.1136/bmjqs-2023-016690.
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psnet.ahrq.gov/issue/mitigating-hazards-through-continuing-design-birth-and-evolution-pediatric-intensive-care
April 06, 2011 - Commentary
Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit.
Citation Text:
Madsen P, Desai V, Roberts K, et al. Mitigating Hazards Through Continuing Design: The Birth and Evolution of a Pediatric Intensive Care Unit. Organizati…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/simon-sr-et-al-2007
January 01, 2007 - Simon SR et al. 2007 "Physicians and electronic health records - a statewide survey."
Reference
Simon SR, Kaushal R, Cleary PD, et al. Physicians and electronic health records: a statewide survey. Arch Intern Med 2007;167(5):507-512.
[Link]
Abstract
"Background: Electronic health records (EH…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/hoch-i-et-al-2003
January 01, 2003 - Hoch I et al. 2003 "Countrywide computer alerts to community physicians improve potassium testing in patients receiving diuretics."
Reference
Hoch I, Heymann AD, Kurman I, et al. Countrywide computer alerts to community physicians improve potassium testing in patients receiving diuretics. J Am Med Inf…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/ahcptemplsp.docx
June 02, 2025 - Template for Manual Creation of the AHCP: Spanish-Speaking Patients
** Triaga este plan a TODAS sus citas **
Plan de Cuidado Para:
[Patient name]
Dia de Alta: [discharge date]
¿Preguntas o problemas sobre este paquete?
Llame a su transición a la portada enfermera: (xxx) xxx-xxxx DE PHOTO HERE
¿Problemas serios de …
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psnet.ahrq.gov/issue/adverse-events-hospitals-quarter-medicare-patients-experienced-harm-october-2018
February 01, 2023 - Book/Report
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.
Citation Text:
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Grimm CA. Washington DC: Office of the Inspector General; May 2022. Repor…
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psnet.ahrq.gov/issue/nursing-strategies-increase-medication-safety-inpatient-settings
September 21, 2016 - Study
Nursing strategies to increase medication safety in inpatient settings.
Citation Text:
Bravo K, Cochran GL, Barrett R. Nursing Strategies to Increase Medication Safety in Inpatient Settings. J Nurs Care Qual. 2016;31(4):335-41. doi:10.1097/NCQ.0000000000000181.
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psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
June 21, 2016 - Book/Report
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
Citation Text:
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
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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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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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digital.ahrq.gov/principal-investigator/lafleur-joanne
January 01, 2023 - Lafleur, Joanne
Predictors of early discontinuation of pegylated interferon for reasons other than lack of efficacy in United States Veterans with chronic hepatitis C.
Citation
LaFleur J, Hoop R, Korner E, et al. Predictors of early discontinuation of pegylated interferon for…
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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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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…