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psnet.ahrq.gov/node/43394/psn-pdf
July 30, 2014 - With oral chemotherapy, we simply must do better!
July 30, 2014
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter
…
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psnet.ahrq.gov/node/43269/psn-pdf
July 28, 2014 - Restoring trust in VA health care.
July 28, 2014
Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297.
doi:10.1056/NEJMp1406852.
https://psnet.ahrq.gov/issue/restoring-trust-va-health-care
In response to a recent investigation raising concerns about inaccurate reporting of wait-ti…
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psnet.ahrq.gov/node/44121/psn-pdf
May 13, 2015 - Educating medical trainees on medication reconciliation:
a systematic review.
May 13, 2015
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a
systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
https://psnet.ahrq.gov/issue/educating-medic…
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psnet.ahrq.gov/node/43430/psn-pdf
October 20, 2014 - Positive deviance: a different approach to achieving
patient safety.
October 20, 2014
Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient
safety. BMJ Qual Saf. 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115.
https://psnet.ahrq.gov/issue/positive-deviance-diffe…
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psnet.ahrq.gov/node/45058/psn-pdf
February 18, 2017 - Learning from incidents in healthcare: the journey, not
the arrival, matters.
February 18, 2017
Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival,
matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853.
https://psnet.ahrq.gov/issue/learni…
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psnet.ahrq.gov/node/73594/psn-pdf
August 11, 2021 - 'There is a real cost’: as Covid shows, barring bedside
visitors from ICU deprives patients of the best care.
August 11, 2021
Renault M. STAT. July 28, 2021.
https://psnet.ahrq.gov/issue/there-real-cost-covid-shows-barring-bedside-visitors-icu-deprives-patients-
best-care
Care and safety concerns for patients, fa…
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psnet.ahrq.gov/node/853977/psn-pdf
September 27, 2023 - Patient safety: listen to whistleblowers.
September 27, 2023
Kirkup B, Titcombe J. Patient safety: listen to whistleblowers. BMJ. 2023;382:1972. doi:10.1136/bmj.p1972.
https://psnet.ahrq.gov/issue/patient-safety-listen-whistleblowers
The latent nature of failure in health care is enabled by organizational inability…
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psnet.ahrq.gov/node/837908/psn-pdf
August 24, 2022 - Implication of the COVID-19 Pandemic for Patient Safety:
A Rapid Review.
August 24, 2022
Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN:
9789240055094.
https://psnet.ahrq.gov/issue/implication-covid-19-pandemic-patient-safety-rapid-review
The COVID-19 pandemic created new r…
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psnet.ahrq.gov/node/38425/psn-pdf
January 29, 2010 - Hospitalists as Emerging Leaders in Patient Safety:
lessons learned and future directions.
January 29, 2010
Flanders S, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: lessons learned
and future directions. J Patient Saf. 2009;5(1):3-8. doi:10.1097/PTS.0b013e31819751f2.
https://psne…
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psnet.ahrq.gov/node/40603/psn-pdf
December 31, 2014 - ICU nurses' acceptance of electronic health records.
December 31, 2014
Carayon P, Cartmill R, Blosky MA, et al. ICU nurses' acceptance of electronic health records. J Am Med
Inform Assoc. 2011;18(6):812-9. doi:10.1136/amiajnl-2010-000018.
https://psnet.ahrq.gov/issue/icu-nurses-acceptance-electronic-health-records
…
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psnet.ahrq.gov/node/36087/psn-pdf
September 28, 2010 - Improving patient safety in hospitals: contributions of
high-reliability theory and normal accident theory.
September 28, 2010
Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and
normal accident theory. Health Serv Res. 2006;41(4 Pt 2):1654-76.
https://psnet.ah…
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psnet.ahrq.gov/node/46659/psn-pdf
December 06, 2017 - Focus On: Health Care Policy and Quality.
December 6, 2017
AJR Am J Roentgenol. 2017;209(5):965-1008;w333-w334.
https://psnet.ahrq.gov/issue/focus-health-care-policy-and-quality
Radiologists play a critical role in safe diagnostic imaging and communication of test results. Articles in this
special issue explore cl…
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psnet.ahrq.gov/node/34599/psn-pdf
January 30, 2008 - Organizational Learning from Experience in High-Hazard
Industries: Problem Investigations as Off-line Reflective
Practice.
January 30, 2008
Carroll JS, Rudolph JW, Hatakenaka S. Cambridge, MA: MIT Sloan School of Management; 2002. Working
Paper 4359-02
https://psnet.ahrq.gov/issue/organizational-learning-experien…
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psnet.ahrq.gov/node/38707/psn-pdf
June 17, 2009 - Doctors' views of attitudes towards peer medical error.
June 17, 2009
Asghari F, Fotouhi A, Jafarian A. Doctors' views of attitudes towards peer medical error. Qual Saf Health
Care. 2009;18(3):209-12. doi:10.1136/qshc.2007.025015.
https://psnet.ahrq.gov/issue/doctors-views-attitudes-towards-peer-medical-error
The …
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psnet.ahrq.gov/node/42415/psn-pdf
July 24, 2013 - Strategies for improving communication in the
emergency department: mediums and messages in a
noisy environment.
July 24, 2013
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency
department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…
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psnet.ahrq.gov/node/43826/psn-pdf
June 01, 2015 - Radiation Oncology Incident Learning System.
June 1, 2015
American Society for Radiation Oncology and American Association of Physicists in Medicine.
https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
Reporting of near misses and adverse events can provide a foundation for learning from error.…
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psnet.ahrq.gov/node/46333/psn-pdf
June 25, 2018 - High reliability leadership: a conceptual framework.
June 25, 2018
Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage.
2017;26(2):237-246. doi:10.1111/1468-5973.12187.
https://psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework
Leadership engag…
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psnet.ahrq.gov/node/60833/psn-pdf
September 15, 2020 - Enhancing Your Medication Error Reporting Program to
Improve Global Medication Safety.
August 19, 2020
Institute for Safe Medication Practices. September 15, 2020.
https://psnet.ahrq.gov/issue/enhancing-your-medication-error-reporting-program-improve-global-
medication-safety
Medication error reporting is key to …
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psnet.ahrq.gov/node/46590/psn-pdf
November 01, 2017 - High-alert medications: the safeguards that you should
put in place to reduce risks.
November 1, 2017
Blank C. Drug Topics. October 13, 2017.
https://psnet.ahrq.gov/issue/high-alert-medications-safeguards-you-should-put-place-reduce-risks
This magazine article reports on high-alert medications, their potential to …
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psnet.ahrq.gov/node/40620/psn-pdf
July 22, 2011 - The role of documents and documentation in
communication failure across the perioperative pathway.
A literature review.
July 22, 2011
Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the
perioperative pathway. A literature review. Int J Nurs Stud. 2011;48(8):1024-…