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psnet.ahrq.gov/node/47162/psn-pdf
August 15, 2018 - Evaluation of the frequency of dispensing electronically
discontinued medications and associated outcomes.
August 15, 2018
Copi EJ, Kelley LR, Fisher KK. Evaluation of the frequency of dispensing electronically discontinued
medications and associated outcomes. J Am Pharm Assoc (2003). 2018;58(4S):S46-S50.
doi:10.1…
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psnet.ahrq.gov/node/851067/psn-pdf
June 28, 2023 - Assessing medication safety in settings not designated
solely for pediatric patients.
June 28, 2023
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
Pediatric patients are at increa…
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psnet.ahrq.gov/node/40169/psn-pdf
January 26, 2011 - The association between night or weekend admission and
hospitalization-relevant patient outcomes.
January 26, 2011
Khanna R, Wachsberg K, Marouni A, et al. The association between night or weekend admission and
hospitalization-relevant patient outcomes. J Hosp Med. 2011;6(1):10-4. doi:10.1002/jhm.833.
https://psne…
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psnet.ahrq.gov/node/60668/psn-pdf
July 08, 2020 - Preserving organizational resilience, patient safety, and
staff retention during COVID-19 requires a holistic
consideration of the psychological safety of healthcare
workers
July 8, 2020
Rangachari P, L. Woods J. Preserving organizational resilience, patient safety, and staff retention during
COVID-19 requires a …
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psnet.ahrq.gov/node/61051/psn-pdf
October 21, 2020 - Safety investigations from across the pond: deep learning
from England’s Healthcare Safety Investigation Branch
(HSIB).
October 21, 2020
ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4
https://psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safe…
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psnet.ahrq.gov/node/866824/psn-pdf
September 25, 2024 - 'Failing wisely' can promote a safer healthcare system.
September 25, 2024
Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today.
September 17, 2024;
https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
The ability to learn-by-doing in an enviro…
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psnet.ahrq.gov/node/843094/psn-pdf
January 25, 2023 - Getting Started with a Communication and Resolution
Program (CRP) Policy or Commitment Statement to CR.
January 25, 2023
Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of
Washington; 2022
https://psnet.ahrq.gov/issue/getting-started-communication-and-resolution-program-c…
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psnet.ahrq.gov/node/72481/psn-pdf
November 18, 2020 - Computer-based simulation to reduce EHR-related
chemotherapy ordering errors.
November 18, 2020
Wyatt KD, Freedman EB, Arteaga GM, et al. Computer?based simulation to reduce EHR?related
chemotherapy ordering errors. Cancer Med. 2020;9(23):8844-8851. doi:10.1002/cam4.3496.
https://psnet.ahrq.gov/issue/computer-base…
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psnet.ahrq.gov/node/73965/psn-pdf
October 13, 2021 - Association of simulation training with rates of medical
malpractice claims among obstetrician-gynecologists.
October 13, 2021
Schaffer AC, Babayan A, Einbinder JS, et al. Association of simulation training with rates of medical
malpractice claims among obstetrician-gynecologists. Obstet Gynecol. 2021;138(2):246-25…
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psnet.ahrq.gov/node/44259/psn-pdf
April 01, 2024 - Training Program for Nurses on Shift Work and Long
Work Hours.
April 1, 2024
Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health
and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute
for Occupational Safety and He…
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psnet.ahrq.gov/node/40623/psn-pdf
July 20, 2011 - Policy and practice in the use of root cause analysis to
investigate clinical adverse events: mind the gap.
July 20, 2011
Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical
adverse events: mind the gap. Soc Sci Med. 2011;73(2):217-25. doi:10.1016/j.socscime…
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psnet.ahrq.gov/node/853442/psn-pdf
September 13, 2023 - Pediatric Diagnostic Safety: State of the Science and
Future Directions.
September 13, 2023
Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2023. AHRQ Publication No. 23-0040-5-EF.
https://psnet.ahrq.gov/issue/pediatric-diagnostic-safety-state-scienc…
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psnet.ahrq.gov/node/851357/psn-pdf
July 12, 2023 - The challenge of risk prevention in home healthcare-an
interview study with nurses in municipal care.
July 12, 2023
Lekman J, Lindén E, Ekstedt M. The challenge of risk prevention in home healthcare—an interview study
with nurses in municipal care. Scand J Caring Sci. 2023;37(4):1067-1078. doi:10.1111/scs.13181.
h…
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psnet.ahrq.gov/node/43134/psn-pdf
September 04, 2015 - Evaluating the accuracy of electronic pediatric drug
dosing rules.
September 4, 2015
Kirkendall E, Spooner A, Logan JR. Evaluating the accuracy of electronic pediatric drug dosing rules. J Am
Med Inform Assoc. 2014;21(e1):e43-9. doi:10.1136/amiajnl-2013-001793.
https://psnet.ahrq.gov/issue/evaluating-accuracy-elec…
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psnet.ahrq.gov/node/45009/psn-pdf
March 30, 2016 - Fatal mistakes.
March 30, 2016
Kliff S. Vox Media. March 15, 2016.
https://psnet.ahrq.gov/issue/fatal-mistakes
Health professionals involved in medical errors experience psychological stress, which can have serious
consequences if they are unable to cope with their mistake. Reporting on the second victim phenomeno…
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psnet.ahrq.gov/node/34894/psn-pdf
July 10, 2008 - Hospitalization and death associated with potentially
inappropriate medication prescriptions among elderly
nursing home residents.
July 10, 2008
Lau DT, Kasper JD, Potter DEB, et al. Hospitalization and death associated with potentially inappropriate
medication prescriptions among elderly nursing home residents. A…
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psnet.ahrq.gov/node/34914/psn-pdf
February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database.
February 27, 2009
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3…
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psnet.ahrq.gov/node/45378/psn-pdf
January 23, 2017 - Quantitative analysis of the content of EMS handoff of
critically ill and injured patients to the emergency
department.
January 23, 2017
Goldberg SA, Porat A, Strother CG, et al. Quantitative Analysis of the Content of EMS Handoff of Critically
Ill and Injured Patients to the Emergency Department. Prehosp Emerg Ca…
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psnet.ahrq.gov/node/47033/psn-pdf
June 06, 2018 - Post-hospital medication discrepancies at home: risk
factor for 90-day return to emergency department.
June 6, 2018
Costa LL, Byon HD. Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to
Emergency Department. J Nurs Care Qual. 2018;33(2):180-186. doi:10.1097/NCQ.0000000000000278.
https…
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psnet.ahrq.gov/node/46922/psn-pdf
January 01, 2019 - Reducing interdisciplinary communication failures
through secure text messaging: a quality improvement
project.
March 21, 2018
Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure
Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/pq9.0000000000000053.
https://ps…