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psnet.ahrq.gov/node/841154/psn-pdf
December 07, 2022 - Concerns regarding tablet splitting: a systematic review.
December 7, 2022
Saran AK, Holden NA, Garrison SR. Concerns regarding tablet splitting: a systematic review. BJGP Open.
2022;6(3):BJGPO.2022.0001. doi:10.3399/bjgpo.2022.0001.
https://psnet.ahrq.gov/issue/concerns-regarding-tablet-splitting-systematic-review…
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psnet.ahrq.gov/node/40168/psn-pdf
December 21, 2014 - Variation in surgical time-out and site marking within
pediatric otolaryngology.
December 21, 2014
Shah RK, Arjmand E, Roberson DW, et al. Variation in surgical time-out and site marking within pediatric
otolaryngology. Arch Otolaryngol Head Neck Surg. 2011;137(1):69-73. doi:10.1001/archoto.2010.232.
https://psnet…
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psnet.ahrq.gov/node/50781/psn-pdf
January 08, 2020 - Harnessing the power of medical malpractice data to
improve patient care.
January 8, 2020
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care.
J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
https://psnet.ahrq.gov/issue/harnessing-power-medic…
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psnet.ahrq.gov/node/34660/psn-pdf
December 24, 2008 - Building a learning organization.
December 24, 2008
Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91.
https://psnet.ahrq.gov/issue/building-learning-organization
Garvin, a Harvard Business School professor, postulates that for organizations to truly improve over time
and succeed, they ne…
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psnet.ahrq.gov/node/46241/psn-pdf
January 30, 2018 - Interventions to improve oral chemotherapy safety and
quality: a systematic review.
January 30, 2018
Zerillo JA, Goldenberg BA, Kotecha RR, et al. Interventions to Improve Oral Chemotherapy Safety and
Quality. JAMA Oncol. 2017;4(1):105-117. doi:10.1001/jamaoncol.2017.0625.
https://psnet.ahrq.gov/issue/intervention…
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psnet.ahrq.gov/node/838929/psn-pdf
October 26, 2022 - Toolkit To Improve Antibiotic Use in Ambulatory Care.
October 26, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit a…
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/40059/psn-pdf
April 24, 2011 - Use of the Safety Attitudes Questionnaire as a measure in
patient safety improvement.
April 24, 2011
Watts B, Percarpio KB, West P, et al. Use of the Safety Attitudes Questionnaire as a measure in patient
safety improvement. J Patient Saf. 2010;6(4):206-9.
https://psnet.ahrq.gov/issue/use-safety-attitudes-question…
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psnet.ahrq.gov/node/41838/psn-pdf
December 04, 2016 - Modern palliative radiation treatment: do complexity and
workload contribute to medical errors?
December 4, 2016
D'Souza N, Holden L, Robson S, et al. Modern palliative radiation treatment: do complexity and workload
contribute to medical errors? Int J Radiat Oncol Biol Phys. 2012;84(1):e43-8.
doi:10.1016/j.ijrobp…
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psnet.ahrq.gov/node/42720/psn-pdf
November 13, 2013 - Workplace bullying in the OR: results of a descriptive
study.
November 13, 2013
Chipps E, Stelmaschuk S, Albert NM, et al. Workplace Bullying in the OR: Results of a Descriptive Study.
AORN J. 2013;98(5). doi:10.1016/j.aorn.2013.08.015.
https://psnet.ahrq.gov/issue/workplace-bullying-or-results-descriptive-study
…
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psnet.ahrq.gov/node/43424/psn-pdf
August 13, 2014 - Office-based anesthesia: safety and outcomes.
August 13, 2014
Shapiro FE, Punwani N, Rosenberg NM, et al. Office-Based Anesthesia. Anesth Analg. 2014;119(2):276-
285. doi:10.1213/ane.0000000000000313.
https://psnet.ahrq.gov/issue/office-based-anesthesia-safety-and-outcomes
Office-based anesthesia has become more w…
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psnet.ahrq.gov/node/40199/psn-pdf
March 03, 2011 - Perspective: malpractice in an academic medical center: a
frequently overlooked aspect of professionalism
education.
March 3, 2011
Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a
frequently overlooked aspect of professionalism education. Acad Med. 2011;86(3):365-8.…
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psnet.ahrq.gov/node/50600/psn-pdf
October 30, 2019 - HHS Guide for Clinicians on the Appropriate Dosage
Reduction or Discontinuation of Long-Term Opioid
Analgesics.
October 30, 2019
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid
Analgesics. Washington DC: US Department of Health and Human Services. October 2019.
…
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psnet.ahrq.gov/node/43996/psn-pdf
November 10, 2018 - When doing wrong feels so right: normalization of
deviance.
November 10, 2018
Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf.
2018;14(1):1-2. doi:10.1097/PTS.0000000000000157.
https://psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
This…
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psnet.ahrq.gov/node/38371/psn-pdf
January 28, 2009 - Continuous monitoring of adverse events: influence on
the quality of care and the incidence of errors in general
surgery.
January 28, 2009
Rebasa P, Mora L, Luna A, et al. Continuous monitoring of adverse events: influence on the quality of care
and the incidence of errors in general surgery. World J Surg. 2009;33…
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psnet.ahrq.gov/node/46636/psn-pdf
January 24, 2018 - Drug shortages continue to compromise patient care.
January 24, 2018
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…
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psnet.ahrq.gov/node/46746/psn-pdf
March 07, 2018 - Safety with nebulized medications requires an
interdisciplinary team approach.
March 7, 2018
ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5.
https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach
Myriad system and clinician failures can con…
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psnet.ahrq.gov/node/842777/psn-pdf
January 18, 2023 - Patient safety performance: reversing recent declines
through shared profession-wide system-level solutions.
January 18, 2023
doi:full/10.1056/CAT.22.0318.
https://psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared-
profession-wide-system
The COVID-19 pandemic revealed fractu…
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psnet.ahrq.gov/node/40206/psn-pdf
June 15, 2011 - Frequency of pediatric medication administration errors
and contributing factors.
June 15, 2011
Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and
contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e3182031006.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…