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psnet.ahrq.gov/issue/potentially-fatal-errors-gdh-pqq-glucose-dehydrogenase-pyrroloquinoline-quinone-glucose
June 22, 2011 - Press Release/Announcement
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.
Citation Text:
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. MedWat…
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psnet.ahrq.gov/issue/changing-medical-malpractice-system-align-what-we-know-about-patient-safety-and-quality
September 20, 2012 - Commentary
Changing the medical malpractice system to align with what we know about patient safety and quality improvement.
Citation Text:
Sklar DP. Changing the Medical Malpractice System to Align With What We Know About Patient Safety and Quality Improvement. Acad Med. 2017;92(7):891-8…
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psnet.ahrq.gov/issue/important-change-heparin-container-labels-clearly-state-total-drug-strength
December 16, 2020 - Government Resource
Important change to heparin container labels to clearly state the total drug strength.
Citation Text:
Important change to heparin container labels to clearly state the total drug strength. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; Dece…
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psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-labels-simulation-study
January 14, 2009 - Study
Drug selection errors in relation to medication labels: a simulation study.
Citation Text:
Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a simulation study. Anaesthesia. 2007;62(11):1090-4.
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psnet.ahrq.gov/issue/learning-mistakes-new-zealand-hospitals-what-else-do-we-need-besides-no-fault
March 16, 2022 - Study
Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"?
Citation Text:
Soleimani F. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? N Z Med J. 2006;119(1239):U2099.
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psnet.ahrq.gov/issue/rules-safety-and-narrativisation-identity-hospital-operating-theatre-case-study
June 24, 2010 - Commentary
Rules, safety and the narrativisation of identity: a hospital operating theatre case study.
Citation Text:
McDonald R, Waring J, Harrison S. Rules, safety and the narrativisation of identity: a hospital operating theatre case study. Sociol Health Illn. 2006;28(2):178-202.
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psnet.ahrq.gov/issue/living-will-misinterpreted-dnr-order-confusion-compromises-patient-care
September 11, 2019 - Commentary
A living will misinterpreted as a DNR order: confusion compromises patient care.
Citation Text:
Katsetos AD, Mirarchi FL. A living will misinterpreted as a DNR order: confusion compromises patient care. J Emerg Med. 2011;40(6):629-32. doi:10.1016/j.jemermed.2008.11.014.
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psnet.ahrq.gov/issue/preventing-medication-errors
May 30, 2018 - Commentary
Preventing medication errors.
Citation Text:
Stefanacci RG, Riddle A. Preventing medication errors. Geriatr Nurs. 2016;37(4):307-10. doi:10.1016/j.gerinurse.2016.06.005.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/issue/heroism-safe-design-leveraging-technology
August 17, 2017 - Commentary
From heroism to safe design: leveraging technology.
Citation Text:
Pronovost P, Bo-Linn GW, Sapirstein A. From heroism to safe design: leveraging technology. Anesthesiology. 2014;120(3):526-9. doi:10.1097/ALN.0000000000000127.
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psnet.ahrq.gov/issue/strategies-increase-reporting-near-misses-and-adverse-events
September 30, 2012 - Commentary
Strategies to increase reporting of near misses and adverse events.
Citation Text:
Conerly C. Strategies to increase reporting of near misses and adverse events. J Nurs Care Qual. 2007;22(2):102-6.
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psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text-messaging-quality
May 08, 2017 - Study
Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project.
Citation Text:
Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/…
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psnet.ahrq.gov/issue/homenet-ensuring-patient-safety-medical-device-use-home
June 18, 2014 - Commentary
HomeNet: ensuring patient safety with medical device use in the home.
Citation Text:
Kaufman D, Weick-Brady M. HomeNet: ensuring patient safety with medical device use in the home. Home Healthc Nurse. 2009;27(5):300-7.
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psnet.ahrq.gov/issue/use-pharmaceuticals-dialysis-patients-how-well-do-we-know-our-patients-allergies
March 04, 2011 - Study
The use of pharmaceuticals for dialysis patients. How well do we know our patients' allergies?
Citation Text:
Bhandari S, Armitage J, Chintu M, et al. THE USE OF PHARMACEUTICALS FOR DIALYSIS PATIENTS. HOW WELL DO WE KNOW OUR PATIENTS' ALLERGIES? J Ren Care. 2008;34(4). doi:10.…
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psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
November 26, 2014 - Commentary
Supervision, autonomy, and medical error in the teaching clinic.
Citation Text:
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
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psnet.ahrq.gov/issue/lost-art-doctoring-reflections-pediatric-resident
November 21, 2021 - Commentary
The lost art of doctoring: reflections of a pediatric resident.
Citation Text:
Mitchell SM. The Lost Art of Doctoring: Reflections of a Pediatric Resident. JAMA Pediatr. 2018;172(1):10. doi:10.1001/jamapediatrics.2017.3247.
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psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
August 01, 2018 - Commentary
Changing smart pump vendors: lessons learned.
Citation Text:
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm. 2016;51(9):782-789.
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psnet.ahrq.gov/issue/hospital-admission-medication-reconciliation-medically-complex-children-observational-study
April 24, 2018 - Study
Hospital admission medication reconciliation in medically complex children: an observational study.
Citation Text:
Stone BL, Boehme S, Mundorff MB, et al. Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2009. doi…
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psnet.ahrq.gov/issue/methodology-and-bias-assessing-compliance-surgical-safety-checklist
May 04, 2012 - Study
Methodology and bias in assessing compliance with a surgical safety checklist.
Citation Text:
Poon SJ, Zuckerman SL, Mainthia R, et al. Methodology and bias in assessing compliance with a surgical safety checklist. Jt Comm J Qual Patient Saf. 2013;39(2):77-82.
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psnet.ahrq.gov/issue/internal-medicine-work-hours-trends-associations-and-implications-future
February 03, 2016 - Study
Internal medicine work hours: trends, associations, and implications for the future.
Citation Text:
Shiotani LM, Parkerton PH, Wenger N, et al. Internal medicine work hours: trends, associations, and implications for the future. Am J Med. 2008;121(1):80-5. doi:10.1016/j.amjmed.20…
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psnet.ahrq.gov/issue/case-study-safety-impact-implementing-smart-patient-controlled-analgesic-pumps-tertiary-care
August 31, 2016 - Study
A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.
Citation Text:
Tran M, Ciarkowski S, Wagner D, et al. A case study on the safety impact of implementing smart patient-controlled analgesic pumps at…