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psnet.ahrq.gov/node/60667/psn-pdf
July 08, 2020 - Nurse health, work environment, presenteeism and
patient safety.
July 8, 2020
Rainbow JG, Drake DA, Steege LM. Nurse health, work environment, presenteeism and patient safety.
West J Nurs Res. 2020;42(5):332-339. doi:10.1177/0193945919863409.
https://psnet.ahrq.gov/issue/nurse-health-work-environment-presenteeism-…
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psnet.ahrq.gov/node/43791/psn-pdf
December 17, 2014 - Facilitating Patient Understanding of Discharge
Instructions: Workshop Summary.
December 17, 2014
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN:
9780309307383.
https:…
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psnet.ahrq.gov/node/46936/psn-pdf
April 11, 2018 - You've detailed your last wishes, but doctors may not see
them.
April 11, 2018
Lamas D.
https://psnet.ahrq.gov/issue/youve-detailed-your-last-wishes-doctors-may-not-see-them
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread.
Reporting on a physician's experienc…
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psnet.ahrq.gov/node/73969/psn-pdf
October 26, 2021 - Important Actions Community Pharmacists Need to Take
Now to Reduce Potentially Harmful Dispensing Errors.
October 13, 2021
Institute for Safe Medication Practices. October 26, 2021.
https://psnet.ahrq.gov/issue/important-actions-community-pharmacists-need-take-now-reduce-potentially-
harmful-dispensing
Community …
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psnet.ahrq.gov/node/41169/psn-pdf
May 19, 2014 - Risk factors for patient-reported medical errors in eleven
countries.
May 19, 2014
Schwappach DLB. Risk factors for patient-reported medical errors in eleven countries. Health Expect.
2014;17(3):321-31. doi:10.1111/j.1369-7625.2011.00755.x.
https://psnet.ahrq.gov/issue/risk-factors-patient-reported-medical-errors-…
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psnet.ahrq.gov/node/46159/psn-pdf
May 31, 2017 - Despite technology, verbal orders persist, read back is
not widespread, and errors continue.
May 31, 2017
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
https://psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and-
errors-continue
Verbal orders are kno…
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psnet.ahrq.gov/node/37993/psn-pdf
August 20, 2008 - Peer support: healthcare professionals supporting each
other after adverse medical events.
August 20, 2008
van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events.
Qual Saf Health Care. 2008;17(4):249-52. doi:10.1136/qshc.2007.025536.
https://psnet.ahrq.gov/issue/peer-…
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psnet.ahrq.gov/node/48075/psn-pdf
June 19, 2019 - A mismatch made in America.
June 19, 2019
Butcher L. Managed Care. June 2019;28:37-39.
https://psnet.ahrq.gov/issue/mismatch-made-america
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient
errors. This magazine article reports on the complex nature of addressing …
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psnet.ahrq.gov/node/50593/psn-pdf
October 30, 2019 - Using video to assess and improve patient safety during
simulated and actual neonatal resuscitation.
October 30, 2019
Leone TA. Using video to assess and improve patient safety during simulated and actual neonatal
resuscitation. Semin Perinatol. 2019;43(8):151179. doi:10.1053/j.semperi.2019.08.008.
https://psnet.a…
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psnet.ahrq.gov/node/44895/psn-pdf
March 09, 2016 - On patient safety: when are we too old to operate?
March 9, 2016
Lee MJ. On Patient Safety: When Are We Too Old to Operate? Clin Orthop Relat Res. 2016;474(4):895-8.
doi:10.1007/s11999-016-4722-6.
https://psnet.ahrq.gov/issue/patient-safety-when-are-we-too-old-operate
High-risk industries often have mandatory requ…
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psnet.ahrq.gov/node/45099/psn-pdf
December 07, 2018 - Improving Patient Safety in Ambulatory Surgery Centers:
A Resource List for Users of the AHRQ Ambulatory
Surgery Center Survey on Patient Safety Culture.
December 7, 2018
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
https://psnet.ahrq.gov/issue/improving-patient-safety-ambulatory-surgery-…
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psnet.ahrq.gov/node/46554/psn-pdf
October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin
pens at home.
October 25, 2017
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. October 12, 2017.
https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…
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psnet.ahrq.gov/node/45409/psn-pdf
May 17, 2021 - ISMP List of High-Alert Medications in Long-Term Care
(LTC) Settings.
May 17, 2021
Horsham, PA: Institute of Safe Medication Practices; 2021
https://psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings
Long-term care patients often have concurrent conditions that increase their risk of…
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psnet.ahrq.gov/node/47038/psn-pdf
July 18, 2018 - Delivering Quality Health Services: A Global Imperative
for Universal Health Coverage.
July 18, 2018
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
https://psnet.ahrq.gov/issue/delivering-quality-health-services-global-imperative-universal-health-coverage
The Crossing the Quality C…
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psnet.ahrq.gov/node/840169/psn-pdf
November 16, 2022 - ISMP survey on tall man (mixed case) lettering to reduce
drug name confusion.
November 16, 2022
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
Mixed case letters are one suggested strategy to reduce look-alike medication na…
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psnet.ahrq.gov/node/47165/psn-pdf
June 13, 2018 - Changing how we think about healthcare improvement.
June 13, 2018
Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014.
doi:10.1136/bmj.k2014.
https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement
In learning organizations, leadership behavior creates a s…
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psnet.ahrq.gov/node/33904/psn-pdf
January 25, 2016 - Healthcare Cost and Utilization Project (HCUP).
January 25, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup
The Healthcare Cost and Utilization Project (HCUP) is a family of databases and related software tools and
products developed throug…
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psnet.ahrq.gov/node/46258/psn-pdf
January 01, 2021 - Development of a trigger tool to identify adverse drug
events in elderly patients with multimorbidity.
August 30, 2017
Guzmán MDT, Banqueri MG, Otero MJ, et al. Development of a Trigger Tool to Identify Adverse Drug
Events in Elderly Patients With Multimorbidity. J Patient Saf. 2021;17(6):e475-e482.
doi:10.1097/PT…
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psnet.ahrq.gov/node/39810/psn-pdf
April 17, 2011 - The missing link: dedicated patient safety education
within top-ranked US nursing school curricula.
April 17, 2011
Howard JN. The missing link: dedicated patient safety education within top-ranked US nursing school
curricula. J Patient Saf. 2010;6(3):165-71.
https://psnet.ahrq.gov/issue/missing-link-dedicated-pati…
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psnet.ahrq.gov/node/837214/psn-pdf
May 25, 2022 - Global Report on Infection Prevention and Control:
Executive Summary.
May 25, 2022
Geneva, Switzerland; World Health Organization; May 5, 2022.
https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary
Healthcare-acquired infection is a persistent systemic problem. This report r…