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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - Why July matters.
July 5, 2016
Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912.
doi:10.1097/ACM.0000000000001196.
https://psnet.ahrq.gov/issue/why-july-matters
Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient
mortality increa…
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January 01, 2021 - When safety event reporting is seen as punitive: "I've
been PSN-ed!"
September 9, 2020
Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as punitive: "I've been
PSN-ed!". Ann Emerg Med. 2021;77(4):449-458. doi:10.1016/j.annemergmed.2020.06.048.
https://psnet.ahrq.gov/issue/when-safety-ev…
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psnet.ahrq.gov/node/45422/psn-pdf
October 12, 2016 - Maths anxiety and medication dosage calculation errors:
a scoping review.
October 12, 2016
Williams B, Davis S. Maths anxiety and medication dosage calculation errors: A scoping review. Nurse
Educ Pract. 2016;20:139-46. doi:10.1016/j.nepr.2016.08.005.
https://psnet.ahrq.gov/issue/maths-anxiety-and-medication-dosag…
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psnet.ahrq.gov/node/39270/psn-pdf
February 03, 2010 - Organization-wide adoption of computerized provider
order entry systems: a study based on diffusion of
innovations theory.
February 3, 2010
Rahimi B, Timpka T, Vimarlund V, et al. Organization-wide adoption of computerized provider order entry
systems: a study based on diffusion of innovations theory. BMC Med Info…
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psnet.ahrq.gov/node/43736/psn-pdf
April 24, 2017 - Seeing risk and allocating responsibility: talk of culture
and its consequences on the work of patient safety.
April 24, 2017
Szymczak JE. Seeing risk and allocating responsibility: talk of culture and its consequences on the work of
patient safety. Soc Sci Med. 2014;120:252-9. doi:10.1016/j.socscimed.2014.09.023.
…
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psnet.ahrq.gov/node/47252/psn-pdf
August 01, 2018 - Communication errors in radiology—pitfalls and how to
avoid them.
August 1, 2018
Waite S, Scott JM, Drexler I, et al. Communication errors in radiology - Pitfalls and how to avoid them. Clin
Imaging. 2018;51:266-272. doi:10.1016/j.clinimag.2018.05.025.
https://psnet.ahrq.gov/issue/communication-errors-radiology-pi…
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psnet.ahrq.gov/node/44883/psn-pdf
February 17, 2016 - Comparison of barcode scanning by pharmacy
technicians and pharmacists' visual checks for final
product verification.
February 17, 2016
Wang BN-T, Brummond P, Stevenson JG. Comparison of barcode scanning by pharmacy technicians and
pharmacists' visual checks for final product verification. Am J Health Syst Pharm. …
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September 26, 2018 - Malnutrition in the hospital: the pharmacist’s role in
prevention and treatment.
September 26, 2018
Decerbo M. Pharmacy Practice News. September 13, 2018.
https://psnet.ahrq.gov/issue/malnutrition-hospital-pharmacists-role-prevention-and-treatment
Parenteral nutrition errors can result in patient malnutrition and …
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psnet.ahrq.gov/node/73356/psn-pdf
June 02, 2021 - Testing and Labeling Medical Devices for Safety in the
Magnetic Resonance (MR) Environment.
June 2, 2021
Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center
for Devices and Radiological Health. May 20, 2021.
https://psnet.ahrq.gov/issue/testing-and-labeling-medical-d…
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psnet.ahrq.gov/node/50710/psn-pdf
December 04, 2019 - Safety in office-based anesthesia: an updated review of
the literature from 2016 to 2019
December 4, 2019
de Lima A, Osman BM, Shapiro FE. Safety in office-based anesthesia. Curr Opin Anaesthesiol.
2019;32(6):749-755. doi:10.1097/aco.0000000000000794.
https://psnet.ahrq.gov/issue/safety-office-based-anesthesia-upd…
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psnet.ahrq.gov/node/48149/psn-pdf
July 31, 2019 - Zero Harm: How to Achieve Patient and Workforce Safety
in Healthcare.
July 31, 2019
Clapper C, Merlino J, Stockmeier C, eds. New York, NY: McGraw-Hill Education; 2019. ISBN:
9781260440928.
https://psnet.ahrq.gov/issue/zero-harm-how-achieve-patient-and-workforce-safety-healthcare
Achieving zero preventable harms h…
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psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…
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psnet.ahrq.gov/node/45912/psn-pdf
May 09, 2017 - Medication reconciliation failures in children and young
adults with chronic disease during intensive and
intermediate care.
May 9, 2017
DeCourcey DD, Silverman M, Chang E, et al. Medication reconciliation failures in children and young adults
with chronic disease during intensive and intermediate care. Pediatr Cr…
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October 14, 2020 - L.A.’s poorest patients endure long delays to see medical
specialists. Some die waiting.
October 14, 2020
Dolan J, Mejia B. Los Angeles Times. September 30, 2020.
https://psnet.ahrq.gov/issue/las-poorest-patients-endure-long-delays-see-medical-specialists-some-die-
waiting
Socioeconomic conditions influence acces…
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June 22, 2022 - Agency Information Collection Activities: Proposed
Collection; Comment Request, "Hospital Survey on
Patient Safety Culture Comparative Database.''
June 22, 2022
Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796.
https://psnet.ahrq.gov/issue/agency-information-collection-a…
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February 12, 2020 - The Rural VA Multi-Center Medication Reconciliation
Quality Improvement Study (R-VA-MARQUIS).
February 12, 2020
Presley CA, Wooldridge KT, Byerly SH, et al. The Rural VA Multi-Center Medication Reconciliation Quality
Improvement Study (R-VA-MARQUIS). Am J Health Syst Pharm. 2020;77(2):128-137.
doi:10.1093/ajhp/zxz…
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May 21, 2016 - The Habits of an Improver. Thinking About Learning for
Improvement in Health Care.
May 21, 2016
Lucas B, Nacer H. London, UK: Health Foundation; October 2015. ISBN: 9781906461676.
https://psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care
Committed leadership is essential to enhan…
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
Citation Text:
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…