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psnet.ahrq.gov/issue/applying-lean-methods-improve-quality-and-safety-surgical-sterile-instrument-processing
September 16, 2015 - Study
Applying Lean methods to improve quality and safety in surgical sterile instrument processing.
Citation Text:
Blackmore C, Bishop R, Luker S, et al. Applying lean methods to improve quality and safety in surgical sterile instrument processing. Jt Comm J Qual Patient Saf. 2013;39(…
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psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable
August 15, 2012 - Study
Is failure mode and effect analysis reliable?
Citation Text:
Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5(2):86-94. doi:10.1097/PTS.0b013e3181a6f040.
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psnet.ahrq.gov/issue/what-measure-safe-hospital-medication-errors-missed-risk-management-clinical-staff-and
September 27, 2017 - Study
What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.
Citation Text:
Grasso BC, Rothschild JM, Jordan CW, et al. What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and su…
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psnet.ahrq.gov/issue/what-does-it-take-case-study-radical-change-toward-patient-safety
September 27, 2017 - Study
What does it take? A case study of radical change toward patient safety.
Citation Text:
Vicente KJ. What does it take? A case study of radical change toward patient safety. Jt Comm J Qual Patient Saf. 2003;29(11):598-609.
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psnet.ahrq.gov/issue/momentary-interruptions-can-derail-train-thought
May 18, 2022 - Study
Momentary interruptions can derail the train of thought.
Citation Text:
Altmann EM, Trafton G, Hambrick DZ. Momentary interruptions can derail the train of thought. J Exp Psychol Gen. 2014;143(1):215-26. doi:10.1037/a0030986.
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psnet.ahrq.gov/issue/value-human-factors-medication-and-patient-safety-intensive-care-unit
December 01, 2010 - Study
Value of human factors to medication and patient safety in the intensive care unit.
Citation Text:
Scanlon M, Karsh B-T. Value of human factors to medication and patient safety in the intensive care unit. Crit Care Med. 2010;38. doi:10.1097/ccm.0b013e3181dd8de2.
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psnet.ahrq.gov/issue/using-medical-error-reporting-drive-patient-safety-efforts
September 18, 2024 - Commentary
Using medical-error reporting to drive patient safety efforts.
Citation Text:
Stow J. Using medical-error reporting to drive patient safety efforts. AORN J. 2006;84(3):406-8, 411-4, 417-20; quiz 421-4.
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psnet.ahrq.gov/issue/perceived-causes-prescribing-errors-junior-doctors-hospital-inpatients-study-protect
April 19, 2011 - Study
Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme.
Citation Text:
Ross S, Ryan C, Duncan EM, et al. Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programm…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - ) gets tricky because it comes down to local
factors, such as how your state is using grant funds, pharmacy … regulations, and whether your
organization will allow you to hand it out or if it has to go through a pharmacy … step for patients, but if you're prescribing other meds and you know your patient is going to the
pharmacy
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - mortality review, and a new protocol was issued that potent medications may be started only after the pharmacy … From the Same Author(s)
Reducing readmission at an academic medical center: results of a pharmacy-facilitated
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Forcing functions might include a pharmacy-triggered warning when neuraxial anesthesia is ordered in … clinician that prior approval from the anticoagulation, pain, or anesthesia service is required, and that pharmacy
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - can play a role in increasing
access to naloxone for pediatric patients, with all states allowing pharmacy … Vital Signs: Pharmacy-Based Naloxone Dispensing –
United States, 2012-2018.
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - Furthermore, because the
pharmacy likely would have received the identical "bad data" (incorrect weight … ) sent through a third-party
broker from the CPOE system to the pharmacy dispensing system, there would
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - authors review a series of interventions designed through the
multidisciplinary efforts of nursing, pharmacy … authors review a series of interventions designed through the
multidisciplinary efforts of nursing, pharmacy
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psnet.ahrq.gov/issue/opioids-and-dentistry
November 12, 2014 - Special or Theme Issue
Opioids and Dentistry.
Citation Text:
Opioids and Dentistry. J Am Dent Assoc. 2018;149(4):237-272. doi:10.1016/j.adaj.2018.02.015.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/medication-errors-electronic-prescribing-ep-two-views-same-picture
November 13, 2009 - Study
Medication errors with electronic prescribing (eP): two views of the same picture.
Citation Text:
Savage I, Cornford T, Klecun E, et al. Medication errors with electronic prescribing (eP): Two views of the same picture. BMC Health Serv Res. 2010;10:135. doi:10.1186/1472-6963-10-1…
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psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
March 16, 2022 - Book/Report
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.
Citation Text:
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/developing-reporting-and-tracking-tool-nursing-student-errors-and-near-misses
September 21, 2009 - Commentary
Developing a reporting and tracking tool for nursing student errors and near misses.
Citation Text:
Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4.
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psnet.ahrq.gov/issue/human-factors-framework-and-study-effect-nursing-workload-patient-safety-and-employee-quality
May 16, 2012 - Study
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.
Citation Text:
Holden RJ, Scanlon MC, Patel NR, et al. A human factors framework and study of the effect of nursing workload on patient safety and employe…