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psnet.ahrq.gov/issue/frequency-pediatric-medication-administration-errors-and-contributing-factors
November 16, 2022 - Study
Frequency of pediatric medication administration errors and contributing factors.
Citation Text:
Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e31820…
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psnet.ahrq.gov/issue/high-alert-medications-safeguards-you-should-put-place-reduce-risks
May 20, 2020 - Newspaper/Magazine Article
High-alert medications: the safeguards that you should put in place to reduce risks.
Citation Text:
High-alert medications: the safeguards that you should put in place to reduce risks. Blank C. Drug Topics. October 13, 2017.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
January 01, 2018 - New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi)
Optimizing
the Use of HIT
to Improve
Safety
Tejal Gandhi
Handwriting
16
Ways IT Can Improve Safety
• Prevent errors and adverse events
• Facilitating a more rapid response after an
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Guide to Patient and Family Engagement :: 1
Improving Discharge Outcomes with Patients and Families
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.1,2 Re…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/131-what-are-the-4-es-one-pager.docx
May 24, 2024 - The aim is to Engage hearts and minds and thus, change attitudes and behaviors.1-6
Raise awareness of the problem, communicate benefits of the solution, and lay out the goals for the intervention.
· Use unit data, published literature, and national benchmarks. Storytelling is an underrated tool.
Engagement is not a on…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - Transforming Care for People Living with Multiple Chronic Conditions
Transforming Care for People Living with
Multiple Chronic Conditions
Arlene Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality
November 17, 2020
Why MCC?
• Common, Costly
• H…
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psnet.ahrq.gov/issue/disclosure-harmful-medical-error-patients-review-recommendations-pathologists
September 21, 2022 - Review
Disclosure of harmful medical error to patients: a review with recommendations for pathologists.
Citation Text:
Heher YK, Dintzis SM. Disclosure of Harmful Medical Error to Patients: A Review With Recommendations for Pathologists. Adv Anat Pathol. 2018;25(2):124-130. doi:10.1097/P…
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psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
April 05, 2017 - Commentary
The SAGES FUSE program: bridging a patient safety gap.
Citation Text:
Fuchshuber PR, Robinson TN, Feldman LS, et al. The SAGES FUSE program: bridging a patient safety gap. Bull Am Coll Surg. 2014;99(9):18-27.
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psnet.ahrq.gov/issue/model-recovering-medical-errors-coronary-care-unit
June 02, 2010 - Study
A model of recovering medical errors in the coronary care unit.
Citation Text:
Hurley A, Rothschild JM, Moore ML, et al. A model of recovering medical errors in the coronary care unit. Heart Lung. 2008;37(3):219-26. doi:10.1016/j.hrtlng.2007.06.002.
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psnet.ahrq.gov/issue/patients-and-families-perspectives-patient-safety-end-life-video-reflexive-ethnography-study
December 18, 2013 - Study
Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study.
Citation Text:
Collier A, Sorensen R, Iedema R. Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study. Int J Qual…
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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.
Co…
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psnet.ahrq.gov/issue/pediatric-perioperative-medication-errors
July 10, 2024 - Newspaper/Magazine Article
Pediatric perioperative medication errors.
Citation Text:
Lu-Boettcher YE, Koka R. Pediatric perioperative medication errors. APSF Newsletter. 39(3):84-86.
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psnet.ahrq.gov/issue/intralipid-medication-errors-neonatal-intensive-care-unit
January 02, 2017 - Study
Intralipid medication errors in the neonatal intensive care unit.
Citation Text:
Chuo J, Lambert G, Hicks RW. Intralipid medication errors in the neonatal intensive care unit. Jt Comm J Qual Patient Saf. 2007;33(2):104-11.
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psnet.ahrq.gov/issue/hospitalization-associated-disability-she-was-probably-able-ambulate-im-not-sure
August 04, 2015 - Study
Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure."
Citation Text:
Covinsky KE, Pierluissi E, Johnston B. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure". JAMA. 2011;306(16):1782-93. doi:10.1001…
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psnet.ahrq.gov/issue/patient-assisted-incident-reporting-including-patient-patient-safety
June 16, 2011 - Commentary
Patient-assisted incident reporting: including the patient in patient safety.
Citation Text:
Millman A, Pronovost P, Makary MA, et al. Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf. 2011;7(2):106-8. doi:10.1097/PTS.0b013e31821b3c…
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psnet.ahrq.gov/issue/misdiagnosis-analysis-based-case-record-review-proposals-aimed-improve-diagnostic-processes
November 12, 2014 - Study
Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.
Citation Text:
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. Clin Med (Lond). 2011;11(…
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psnet.ahrq.gov/issue/ashp-guidelines-remote-medication-order-processing
April 19, 2013 - Commentary
ASHP guidelines on remote medication order processing.
Citation Text:
Processing ASHPEP on RMO, Thompson B, Conrad G, et al. ASHP guidelines on remote medication order processing. Am J Health Syst Pharm. 2010;67(8):672-7. doi:10.2146/sp100003.
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psnet.ahrq.gov/issue/medication-safety-education-program-reduce-risk-harm-caused-medication-errors
June 27, 2018 - Commentary
A medication safety education program to reduce the risk of harm caused by medication errors.
Citation Text:
Dennison RD. A medication safety education program to reduce the risk of harm caused by medication errors. J Contin Educ Nurs. 2007;38(4):176-84.
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psnet.ahrq.gov/issue/adverse-drug-events-elderly
April 21, 2011 - Review
Adverse drug events in the elderly.
Citation Text:
Cresswell KM, Fernando B, McKinstry B, et al. Adverse drug events in the elderly. Br Med Bull. 2007;83(1). doi:10.1093/bmb/ldm016.
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psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma
March 07, 2018 - Study
Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.
Citation Text:
Howie WO, Dutton RP. Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot…