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psnet.ahrq.gov/node/36190/psn-pdf
May 27, 2011 - Lessons from "unexpected increased mortality after
implementation of a commercially sold computerized
physician order entry system."
May 27, 2011
Sittig DF, Ash JS, Zhang J, et al. Lessons from "Unexpected increased mortality after implementation of a
commercially sold computerized physician order entry system". P…
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psnet.ahrq.gov/node/41948/psn-pdf
January 09, 2013 - Implementation of computerized prescriber order entry in
four academic medical centers.
January 9, 2013
Cooley TW, May D, Alwan M, et al. Implementation of computerized prescriber order entry in four academic
medical centers. Am J Health Syst Pharm. 2012;69(24):2166-73. doi:10.2146/ajhp120108.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-safety-requires
November 23, 2016 - Book/Report
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Citation Text:
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Heal…
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psnet.ahrq.gov/issue/improving-hand-communication
April 24, 2007 - Book/Report
Classic
Improving Hand-Off Communication.
Citation Text:
Improving Hand-Off Communication. Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
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psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
June 10, 2018 - Newspaper/Magazine Article
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.
Citation Text:
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1…
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psnet.ahrq.gov/issue/medical-abbreviations-have-contradictory-or-ambiguous-meanings
November 18, 2020 - Newspaper/Magazine Article
Medical abbreviations that have contradictory or ambiguous meanings.
Citation Text:
Medical abbreviations that have contradictory or ambiguous meanings. Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5.
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psnet.ahrq.gov/issue/ahrq-safety-program-end-stage-renal-disease-facilities-toolkit
December 24, 2008 - Government Resource
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
Citation Text:
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
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psnet.ahrq.gov/issue/improving-your-office-testing-process-step-step-guide-rapid-cycle-patient-safety-and-quality
October 23, 2019 - Toolkit
Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement.
Citation Text:
Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement. Rockville, MD: Agency for Healthc…
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psnet.ahrq.gov/issue/findings-and-lessons-enabling-patient-centered-care-through-health-it-grant-initiative
October 05, 2015 - Book/Report
Findings and Lessons From the Enabling Patient-Centered Care Through Health IT Grant Initiative.
Citation Text:
Findings and Lessons From the Enabling Patient-Centered Care Through Health IT Grant Initiative. Rockville, MD: Agency for Healthcare Research and Quality; Ja…
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psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
April 22, 2020 - Multi-use Website
Radiation Oncology Incident Learning System.
Citation Text:
Radiation Oncology Incident Learning System. American Society for Radiation Oncology and American Association of Physicists in Medicine.
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psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
May 05, 2021 - Newspaper/Magazine Article
Addiction treatment providers in Pa. face little state scrutiny despite harm to clients.
Citation Text:
Addiction treatment providers in Pa. face little state scrutiny despite harm to clients. Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
Co…
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psnet.ahrq.gov/issue/promethazine-hcl-marketed-phenergan-information
May 04, 2015 - Government Resource
Promethazine HCl (marketed as Phenergan) Information.
Citation Text:
Promethazine HCl (marketed as Phenergan) Information. FDA; Food and Drug Administration; CDER; Center for Drug Evaluation and Research
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psnet.ahrq.gov/issue/handoffs-and-fumbles
June 12, 2007 - Book/Report
Handoffs and fumbles.
Citation Text:
Handoffs and fumbles. Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols-both-handwritten-and-computer-generated-information
May 07, 2018 - Newspaper/Magazine Article
Misidentification of alphanumeric symbols in both handwritten and computer-generated information.
Citation Text:
Misidentification of alphanumeric symbols in both handwritten and computer-generated information. ISMP Medication Safety Alert! Acute Care Edition. …
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psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
June 10, 2018 - Newspaper/Magazine Article
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.
Citation Text:
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety…
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psnet.ahrq.gov/issue/reducing-latent-errors-drift-errors-and-stakeholder-dissonance
December 14, 2010 - Commentary
Reducing latent errors, drift errors, and stakeholder dissonance.
Citation Text:
Reducing latent errors, drift errors, and stakeholder dissonance. Samaras GM. Work: J Prev Assess Rehabil. 2012;41:1948-1955.
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psnet.ahrq.gov/issue/situational-awareness-and-patient-safety-learning-package
September 13, 2017 - Book/Report
Situational Awareness and Patient Safety: A Learning Package.
Citation Text:
Situational Awareness and Patient Safety: A Learning Package. Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100…