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psnet.ahrq.gov/node/72478/psn-pdf
November 18, 2020 - The impact of the use of employee functional flexibility on
patient safety.
November 18, 2020
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient
safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
https://psnet.ahrq.gov/issue/impact-use-empl…
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psnet.ahrq.gov/node/863765/psn-pdf
March 06, 2024 - Patient safety and artificial intelligence in clinical care.
March 6, 2024
Ratwani RM, Bates DW, Classen DC. Patient safety and artificial intelligence in clinical care. JAMA Health
Forum. 2024;5(2):e235514. doi:10.1001/jamahealthforum.2023.5514.
https://psnet.ahrq.gov/issue/patient-safety-and-artificial-intelligen…
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psnet.ahrq.gov/node/45571/psn-pdf
January 18, 2017 - How communication among members of the health care
team affects maternal morbidity and mortality.
January 18, 2017
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects
Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884.
doi:10.1016/j.jogn.2016.03…
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psnet.ahrq.gov/node/43942/psn-pdf
March 11, 2015 - FDA requires label warnings to prohibit sharing of multi-
dose diabetes pen devices among patients.
March 11, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
https://psnet.ahrq.gov/issue/fda-requires-label-warnings-prohibit-sharing-multi-dose-diabetes-pen-device…
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psnet.ahrq.gov/node/74018/psn-pdf
October 27, 2021 - Anatomy of a medical device recall: how defective
products can slip through an outdated system.
October 27, 2021
Zipp R. Medical Tech Dive. October 18, 2021.
https://psnet.ahrq.gov/issue/anatomy-medical-device-recall-how-defective-products-can-slip-through-
outdated-system
This article highlights systems influenc…
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psnet.ahrq.gov/node/45702/psn-pdf
January 25, 2017 - Implantable infusion pumps in the magnetic resonance
(MR) environment: FDA safety communication—important
safety precautions.
January 25, 2017
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.
https://psnet.ahrq.gov/issue/implantable-infusion-pumps-magnetic-resonance-mr-e…
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psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
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psnet.ahrq.gov/node/837037/psn-pdf
May 04, 2022 - Humanizing harm: using a restorative approach to heal
and learn from adverse events.
May 4, 2022
Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn
from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/hex.13478.
https://psnet.ahrq.gov/issue/hum…
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psnet.ahrq.gov/node/50823/psn-pdf
January 22, 2020 - Reducing inappropriate polypharmacy in primary care
through pharmacy-led interventions.
January 22, 2020
Bryant E, Claire K, Needham R. Reducing inappropriate polypharmacy in primary care through pharmacy-
led interventions. Pharm J. 2019;303(7932). doi:10.1211/pj.2019.20207385.
https://psnet.ahrq.gov/issue/reduci…
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psnet.ahrq.gov/node/37770/psn-pdf
March 10, 2011 - Identifying and quantifying medication errors: evaluation
of rapidly discontinued medication orders submitted to a
computerized physician order entry system.
March 10, 2011
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidly
discontinued medication orders su…
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psnet.ahrq.gov/node/39298/psn-pdf
June 11, 2010 - Medication error reporting in nursing homes: identifying
targets for patient safety improvement.
June 11, 2010
Greene SB, Williams CE, Pierson S, et al. Medication error reporting in nursing homes: identifying targets
for patient safety improvement. Qual Saf Health Care. 2010;19(3):218-22. doi:10.1136/qshc.2008.031…
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psnet.ahrq.gov/node/44001/psn-pdf
May 06, 2015 - Wrong-site nerve blocks: 10 yr experience in a large
multihospital health-care system.
May 6, 2015
Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks: 10 yr experience in a large multihospital
health-care system. Br J Anaesth. 2015;114(5):818-24. doi:10.1093/bja/aeu490.
https://psnet.ahrq.gov/issue/wrong-si…
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psnet.ahrq.gov/node/46011/psn-pdf
January 17, 2018 - Health and Social Care Ergonomics: Patient Safety in
Practice.
January 17, 2018
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
https://psnet.ahrq.gov/issue/health-and-social-care-ergonomics-patient-safety-practice
Human factors engineering strategies offer a range of solutions to improve proce…
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psnet.ahrq.gov/node/44060/psn-pdf
November 16, 2015 - Developing person-centred analysis of harm in a
paediatric hospital: a quality improvement report.
November 16, 2015
Lachman P, Linkson L, Evans T, et al. Developing person-centred analysis of harm in a paediatric hospital:
a quality improvement report. BMJ Qual Saf. 2015;24(5):337-44. doi:10.1136/bmjqs-2014-003795…
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psnet.ahrq.gov/node/73888/psn-pdf
September 29, 2021 - Interventions to reduce medication dispensing,
administration, and monitoring errors in pediatric
professional healthcare settings: a systematic review.
September 29, 2021
Koeck JA, Young NJ, Kontny U, et al. Interventions to reduce medication dispensing, administration, and
monitoring errors in pediatric professi…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/44368/psn-pdf
September 29, 2017 - A systematic review of the effect of distraction on
surgeon performance: directions for operating room
policy and surgical training.
September 29, 2017
Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon
performance: directions for operating room policy and surgical …
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psnet.ahrq.gov/node/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/41389/psn-pdf
June 27, 2012 - Can we make postoperative patient handovers safer? A
systematic review of the literature.
June 27, 2012
Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesth Analg. 2012;115(1):102-15.
doi:10.1213/ANE.0b013e318253af4b.
https:/…
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psnet.ahrq.gov/node/46994/psn-pdf
October 31, 2018 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2017.
October 31, 2018
Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration-2017. Am J Health Syst Pharm. 2018;75(16):1203-1226.
doi:10.…