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psnet.ahrq.gov/node/73064/psn-pdf
March 24, 2021 - Outpatient insulin-related adverse events due to mix-up
errors: findings from two national surveillance systems,
United States, 2012-2017.
March 24, 2021
Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin?related adverse events due to mix?up errors:
Findings from two national surveillance systems, United S…
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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - Use of computerized physician order entry with clinical
decision support to prevent dose errors in pediatric
medication orders: a systematic review.
March 27, 2024
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical
decision support to prevent dose errors in pedia…
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psnet.ahrq.gov/node/853234/psn-pdf
September 06, 2023 - Perceptions and attitudes of pediatricians and families
with regard to pediatric medication errors at home.
September 6, 2023
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. Perceptions and attitudes of pediatricians and families with
regard to pediatric medication errors at home. BMC Pediatr. 2023;23(1):380. doi:10.…
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psnet.ahrq.gov/node/40561/psn-pdf
March 23, 2012 - Principles of conservative prescribing.
March 23, 2012
Schiff G, Galanter W, Duhig J, et al. Principles of conservative prescribing. Arch Intern Med.
2011;171(16):1433-1440. doi:10.1001/archinternmed.2011.256.
https://psnet.ahrq.gov/issue/principles-conservative-prescribing
Strategies to prevent medication errors …
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psnet.ahrq.gov/node/860715/psn-pdf
January 17, 2024 - Development of prescribing indicators related to opioid-
related harm in patients with chronic pain in primary care-
a modified e-Delphi study.
January 17, 2024
Bansal N, Campbell SM, Lin C-Y, et al. Development of prescribing indicators related to opioid-related
harm in patients with chronic pain in primary care—…
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psnet.ahrq.gov/node/37368/psn-pdf
January 10, 2017 - Effective implementation of work-hour limits and
systemic improvements.
January 10, 2017
Landrigan CP, Czeisler CA, Barger LK, et al. Effective implementation of work-hour limits and systemic
improvements. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):19-29.
https://psnet.ahrq.gov/issue/effective-implementation-wo…
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psnet.ahrq.gov/node/856583/psn-pdf
January 01, 2024 - Prescription opioid dose reductions and potential adverse
events: a multi-site observational cohort study in diverse
US health systems.
November 29, 2023
Metz VE, Ray GT, Palzes V, et al. Prescription opioid dose reductions and potential adverse events: a
multi-site observational cohort study in diverse US health …
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psnet.ahrq.gov/node/42113/psn-pdf
March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety
strategy: a systematic review.
March 20, 2013
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008.
https:/…
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psnet.ahrq.gov/issue/shakespeare-was-target-dont-be-borrower-or-lender
May 11, 2022 - Newspaper/Magazine Article
Shakespeare was on target—don't be a borrower or lender.
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June 10, 2018
This piece describes the dangers…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/node/38964/psn-pdf
November 27, 2009 - Development of a measure of patient safety event
learning responses.
November 27, 2009
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning
responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
https://psnet.ahrq.gov/issue/development-…
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psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of
a wrong patient autologous salvaged blood in cardiac
surgery.
October 5, 2022
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong
patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
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psnet.ahrq.gov/node/863748/psn-pdf
March 06, 2024 - Scaling the EQUIPPED medication safety program:
traditional and hub-and-spoke implementation models.
March 6, 2024
Vandenberg AE, Hwang U, Das S, et al. Scaling the EQUIPPED medication safety program: traditional and
hub?and?spoke implementation models. J Am Geriatr Soc. 2024;72(7):2184-2194. doi:10.1111/jgs.18746.…
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psnet.ahrq.gov/node/39985/psn-pdf
November 10, 2010 - Establishing a global learning community for incident-
reporting systems.
November 10, 2010
Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting
systems. Qual Saf Health Care. 2010;19(5):446-51. doi:10.1136/qshc.2009.037739.
https://psnet.ahrq.gov/issue/establishing-…
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psnet.ahrq.gov/node/36975/psn-pdf
March 24, 2011 - Safety of telephone triage in general practitioner
cooperatives: do triage nurses correctly estimate
urgency?
March 24, 2011
Giesen P, Ferwerda R, Tijssen R, et al. Safety of telephone triage in general practitioner cooperatives: do
triage nurses correctly estimate urgency? Qual Saf Health Care. 2007;16(3):181-4.
…
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psnet.ahrq.gov/node/41611/psn-pdf
November 23, 2012 - Self-reported uptake of recommendations after
dissemination of medication incident alerts.
November 23, 2012
Cheung K-C, Wensing M, Bouvy ML, et al. Self-reported uptake of recommendations after dissemination of
medication incident alerts. BMJ Qual Saf. 2012;21(12):1009-18. doi:10.1136/bmjqs-2012-000828.
https://p…
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psnet.ahrq.gov/node/866864/psn-pdf
October 02, 2024 - Patient safety in actioning and communicating blood test
results in primary care: a UK wide audit using the Primary
Care Academic CollaboraTive (PACT).
October 2, 2024
Watson J, Duncan P, Burrell A, et al. Patient safety in actioning and communicating blood test results in
primary care: a UK wide audit using the P…
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psnet.ahrq.gov/node/72649/psn-pdf
January 20, 2021 - Wrong-site surgery in Pennsylvania during 2015–2019: a
study of variables associated with 368 events from 178
facilities.
January 20, 2021
Yonash RA, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables
Associated With 368 Events From 178 Facilities. Patient Safety. 2020;2(4):24-39.
…
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psnet.ahrq.gov/node/46450/psn-pdf
August 20, 2018 - Improving Diagnostic Quality and Safety Final Report.
August 20, 2018
Washington, DC: National Quality Forum. September 19, 2017.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and
mitiga…
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psnet.ahrq.gov/node/48057/psn-pdf
June 26, 2019 - Multicenter study to evaluate the benefits of technology-
assisted workflow on i.v. room efficiency, costs, and
safety.
June 26, 2019
Eckel SF, Higgins JP, Hess E, et al. Multicenter study to evaluate the benefits of technology-assisted
workflow on i.v. room efficiency, costs, and safety. Am J Health-Syst Pharm. 2…