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psnet.ahrq.gov/node/38734/psn-pdf
July 01, 2009 - Safety and efficiency considerations for the introduction
of electronic ordering in a blood bank.
July 1, 2009
Georgiou A, Greenfield T, Callen J, et al. Safety and efficiency considerations for the introduction of
electronic ordering in a blood bank. Arch Pathol Lab Med. 2009;133(6):933-7. doi:10.1043/1543-2165-
…
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psnet.ahrq.gov/node/39696/psn-pdf
January 19, 2011 - Comparison of methods for identifying patients at risk of
medication-related harm.
January 19, 2011
van Doormaal J, Rommers MK, Kosterink JGW, et al. Comparison of methods for identifying patients at risk
of medication-related harm. Qual Saf Health Care. 2010;19(6):e26. doi:10.1136/qshc.2009.033324.
https://psnet.…
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psnet.ahrq.gov/node/38576/psn-pdf
April 22, 2009 - A case of mistaken identity: staff input on patient ID
errors.
April 22, 2009
Ortiz J, Amatucci C. A case of mistaken identity: staff input on patient ID errors. Nurs Manag.
2009;40(4):37-41. doi:10.1097/01.NUMA.0000349689.98615.6d.
https://psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors
…
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psnet.ahrq.gov/node/38503/psn-pdf
June 16, 2009 - Antimicrobial prescription errors in hospitalized children:
role of antimicrobial stewardship program in detection
and intervention.
June 16, 2009
Di Pentima C, Chan S, Eppes SC, et al. Antimicrobial prescription errors in hospitalized children: role of
antimicrobial stewardship program in detection and interventi…
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psnet.ahrq.gov/node/837798/psn-pdf
August 10, 2022 - An evolution of reporting: identifying the missing link.
August 10, 2022
Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics
(Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761.
https://psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link…
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psnet.ahrq.gov/node/37857/psn-pdf
May 26, 2011 - The impact of computerized physician medication order
entry in hospitalized patients—a systematic review.
May 26, 2011
Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in
hospitalized patients--a systematic review. Int J Med Inform. 2008;77(6):365-76.
https://psnet.a…
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psnet.ahrq.gov/node/73898/psn-pdf
September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.
September 29, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.
https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations
In-depth failure investigations provide improvement insights for individuals and or…
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psnet.ahrq.gov/node/34071/psn-pdf
February 18, 2011 - A middle ground on public accountability.
February 18, 2011
Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med.
2004;350(23):2409-2412.
https://psnet.ahrq.gov/issue/middle-ground-public-accountability
This commentary discusses the complex interplay between payers, purchasers, pati…
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psnet.ahrq.gov/node/34048/psn-pdf
May 27, 2011 - Computerized physician order entry: helpful or harmful?
May 27, 2011
Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc.
2004;11(2):100-3.
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful
The authors critically review the published …
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psnet.ahrq.gov/node/43020/psn-pdf
May 29, 2014 - Handoff practices in undergraduate medical education.
May 29, 2014
Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen
Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0.
https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education
This su…
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psnet.ahrq.gov/node/47056/psn-pdf
April 20, 2022 - Healthcare Simulation Week.
April 20, 2022
Society for Simulation in Healthcare.
https://psnet.ahrq.gov/issue/healthcare-simulation-week
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance
individual and team performance. This website provides promotional materials f…
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psnet.ahrq.gov/node/37196/psn-pdf
June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in
neonates, by transposing mcg and mg.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-
and-mg
This article analyzes a…
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psnet.ahrq.gov/node/39582/psn-pdf
April 14, 2011 - Development and early experience from an intervention to
facilitate teamwork between general practices and allied
health providers: the Team-link study.
April 14, 2011
Harris MF, Chan BC, Daniel C, et al. Development and early experience from an intervention to facilitate
teamwork between general practices and all…
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psnet.ahrq.gov/node/73327/psn-pdf
January 25, 2022 - ISMP Medication Safety Self Assessment® for
Perioperative Settings.
January 25, 2022
Institute for Safe Medication Practices
https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
The perioperative setting is a high-risk area for medication errors, should they occur. This asses…
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psnet.ahrq.gov/node/37596/psn-pdf
May 01, 2016 - Patient Safety Organization (PSO) Program.
May 1, 2016
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient
care," the Agency for Healthcare Research…
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psnet.ahrq.gov/node/60672/psn-pdf
July 08, 2020 - The Care We Need
July 8, 2020
Washington DC: National Quality Forum; 2020.
https://psnet.ahrq.gov/issue/care-we-need
This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach
to improve the US health care system. Five strategic objectives are provided--one of which f…
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psnet.ahrq.gov/node/35529/psn-pdf
May 27, 2011 - Case study: identifying potential problems at the
human/technical interface in complex clinical systems.
May 27, 2011
Caudill-Slosberg M, Weeks WB. Case study: identifying potential problems at the human/technical interface
in complex clinical systems. Am J Med Qual. 2005;20(6):353-7.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/39615/psn-pdf
December 17, 2010 - Computerized decision support for medication dosing in
renal insufficiency: a randomized, controlled trial.
December 17, 2010
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal
insufficiency: a randomized, controlled trial. Ann Emerg Med. 2010;56(6):623-9.
doi:10.10…
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psnet.ahrq.gov/node/47847/psn-pdf
July 10, 2024 - CHPSO Annual Reports.
July 10, 2024
California Hospital Patient Safety Organization: Sacramento, CA; 2024.
https://psnet.ahrq.gov/issue/chpso-2019-annual-report
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490
members. This report highlights 2023 trends, activit…
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psnet.ahrq.gov/node/45269/psn-pdf
November 18, 2016 - Surgeons' disclosures of clinical adverse events.
November 18, 2016
Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg.
2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787.
https://psnet.ahrq.gov/issue/surgeons-disclosures-clinical-adverse-events
Even though disclo…