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psnet.ahrq.gov/node/39353/psn-pdf
March 10, 2010 - The impact of a pharmacist's participation on hospitalists'
rounds.
March 10, 2010
Patel R, Butler K, Garrett D, et al. The Impact of a Pharmacist's Participation on Hospitalists' Rounds. Hosp
Pharm. 2010;45(2). doi:10.1310/hpj4502-129.
https://psnet.ahrq.gov/issue/impact-pharmacists-participation-hospitalists-rou…
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psnet.ahrq.gov/node/40134/psn-pdf
February 17, 2011 - Sleep deprivation, elective surgical procedures, and
informed consent.
February 17, 2011
Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed
consent. N Engl J Med. 2010;363(27):2577-9. doi:10.1056/NEJMp1007901.
https://psnet.ahrq.gov/issue/sleep-deprivation-elective-surg…
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psnet.ahrq.gov/node/40312/psn-pdf
June 10, 2018 - Oops, sorry, wrong patient! A patient verification process
is needed everywhere, not just at the bedside.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. March 10, 2011;16:1-4.
https://psnet.ahrq.gov/issue/oops-sorry-wrong-patient-patient-verification-process-needed-everywhere-not-
just-bedside
Th…
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psnet.ahrq.gov/node/38017/psn-pdf
May 02, 2018 - Proper positioning of pharmacy label on Hospira PCA
vials will avoid interference with scanning.
May 2, 2018
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
https://psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-
scanning
This article rep…
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psnet.ahrq.gov/node/46552/psn-pdf
October 25, 2017 - The power of regret.
October 25, 2017
Groopman J, Hartzband P. The Power of Regret. N Engl J Med. 2017;377(16):1507-1509.
doi:10.1056/NEJMp1709917.
https://psnet.ahrq.gov/issue/power-regret
Clinicians may feel regret when the care they provide falls short of their expectations. This commentary
explores how regret…
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psnet.ahrq.gov/node/39669/psn-pdf
July 07, 2010 - ASHP guidelines on remote medication order processing.
July 7, 2010
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.
https://psnet.ahrq.gov/issue/ashp-guidelines-remote-medication-order-proce…
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psnet.ahrq.gov/node/50777/psn-pdf
January 08, 2020 - Safety culture across cultures.
January 8, 2020
Yorio PL, Edwards J, Hoeneveld D. Safety culture across cultures. Safety Sci. 2019;120:402-410.
doi:10.1016/j.ssci.2019.07.021.
https://psnet.ahrq.gov/issue/safety-culture-across-cultures
This paper discusses the relationship between national culture and safety cultu…
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psnet.ahrq.gov/node/46442/psn-pdf
October 04, 2017 - Handoff Communication.
October 4, 2017
APSF Newsletter. October 2017;32:29-56.
https://psnet.ahrq.gov/issue/handoff-communication
Handoff processes are known to carry risks of communication errors. This special issue focuses on
transfers involving anesthesia care. Articles review different types of handoffs, chara…
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psnet.ahrq.gov/node/39094/psn-pdf
June 09, 2011 - Human factors in surgery: from Three Mile Island to the
operating room.
June 9, 2011
D'Addessi A, Bongiovanni L, Volpe A, et al. Human factors in surgery: from Three Mile Island to the
operating room. Urol Int. 2009;83(3):249-57. doi:10.1159/000241662.
https://psnet.ahrq.gov/issue/human-factors-surgery-three-mile-…
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psnet.ahrq.gov/node/34576/psn-pdf
May 27, 2015 - An Agenda for Research in Ambulatory Patient Safety.
May 27, 2015
Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA
https://psnet.ahrq.gov/issue/agenda-research-ambulatory-patient-safety
This summarizes a multidisciplinary conference (November 30 and December 1, 2000)…
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psnet.ahrq.gov/node/37696/psn-pdf
October 13, 2022 - How To Create a My Medicines List.
October 13, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/how-create-my-medicines-list
This tool provides a printable template and step-by-step instructions for patients to create a visual
reference for keeping track of…
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psnet.ahrq.gov/node/46998/psn-pdf
August 01, 2019 - 10 Facts on Patient Safety.
June 27, 2018
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health
Organization: August 2019.
https://psnet.ahrq.gov/issue/10-facts-patient-safety
This publication highlights statistics that illustrate the global impact of patient harm. The i…
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psnet.ahrq.gov/node/39340/psn-pdf
March 17, 2010 - Adverse Events in Hospitals: Methods for Identifying
Events.
March 17, 2010
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; March 2010. Report No. OEI-06-08-00221.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-methods-identifying-events
This report…
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psnet.ahrq.gov/node/43564/psn-pdf
January 15, 2019 - Are hospitals in a med safety standard slump?
January 15, 2019
Wild D. Pharmacy Practice News. September 8, 2014.
https://psnet.ahrq.gov/issue/are-hospitals-med-safety-standard-slump
Highlighting how hospital compliance rates with Joint Commission medication–related standards have
remained mostly unchanged from 20…
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psnet.ahrq.gov/node/39079/psn-pdf
June 06, 2018 - Oral syringes: a crucial and economical risk-reduction
strategy that has not been fully utilized.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.
https://psnet.ahrq.gov/issue/oral-syringes-crucial-and-economical-risk-reduction-strategy-has-not-been-
fully-utilized
This arti…
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psnet.ahrq.gov/node/47805/psn-pdf
May 29, 2019 - Better Health for Mothers and Babies.
May 29, 2019
American Hospital Association.
https://psnet.ahrq.gov/issue/better-health-mothers-and-babies
Maternal harm is a patient safety concern that is increasingly prioritized in regulatory and care delivery
environments. This website provides tools, policies, news articl…
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psnet.ahrq.gov/node/35514/psn-pdf
April 03, 2009 - Information Design for Patient Safety: A Guide to the
Graphic Design of Medication Packaging. 2nd edition.
April 3, 2009
Swayne T. London, UK: National Patient Safety Agency, The Helen Hamlyn Research Centre; 2007.
https://psnet.ahrq.gov/issue/information-design-patient-safety-guide-graphic-design-medication-p…
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psnet.ahrq.gov/node/38287/psn-pdf
February 06, 2009 - Teamwork and patient safety in dynamic domains of
healthcare: a review of the literature.
February 6, 2009
Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta
Anaesthesiol Scand. 2009;53(2):143-51. doi:10.1111/j.1399-6576.2008.01717.x.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/39326/psn-pdf
July 31, 2012 - Initiative to Reduce Unnecessary Radiation Exposure
from Medical Imaging.
July 31, 2012
Center for Devices and Radiological Health; CDRH; US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/initiative-reduce-unnecessary-radiation-exposure-medical-imaging
This Web site provides information on an init…
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psnet.ahrq.gov/node/34923/psn-pdf
February 27, 2009 - Failure mode and effects analysis application to critical
care medicine.
February 27, 2009
Duwe B, Fuchs BD, Hansen-Flaschen J. Failure mode and effects analysis application to critical care
medicine. Crit Care Clin. 2005;21(1):21-30, vii.
https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-application-…