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psnet.ahrq.gov/node/43875/psn-pdf
September 19, 2016 - Implementation of a "second victim" program in a
pediatric hospital.
September 19, 2016
Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital.
Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650.
https://psnet.ahrq.gov/issue/implementation-second-vic…
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psnet.ahrq.gov/node/42825/psn-pdf
December 18, 2013 - Primary care physician communication at hospital
discharge reduces medication discrepancies.
December 18, 2013
Lindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge
reduces medication discrepancies. J Hosp Med. 2013;8(12):672-7. doi:10.1002/jhm.2098.
https://psnet.a…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/node/46750/psn-pdf
January 31, 2018 - Iowans' Views on Medical Errors: Iowa Patient Safety
Study.
January 31, 2018
Clive, IA: Heartland Health Research Institute; January 7, 2018.
https://psnet.ahrq.gov/issue/iowans-views-medical-errors-iowa-patient-safety-study
Patient perspectives can provide insights regarding areas in need of improvement. This sur…
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psnet.ahrq.gov/node/60346/psn-pdf
May 20, 2020 - The need to include assisted living in responding to the
COVID-19 pandemic.
May 20, 2020
Zimmerman S, Sloane PD, Katz PR, et al. The need to include assisted living in responding to the COVID-
19 pandemic. J Am Med Dir Assoc. 2020;21(5). doi:10.1016/j.jamda.2020.03.024.
https://psnet.ahrq.gov/issue/need-include-as…
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psnet.ahrq.gov/node/41173/psn-pdf
February 29, 2012 - Root causes of errors in a simulated prehospital pediatric
emergency.
February 29, 2012
Lammers RL, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency.
Acad Emerg Med. 2012;19(1):37-47. doi:10.1111/j.1553-2712.2011.01252.x.
https://psnet.ahrq.gov/issue/root-causes-errors-simulat…
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psnet.ahrq.gov/node/837209/psn-pdf
May 25, 2022 - Opioids and falls risk in older adults: a narrative review.
May 25, 2022
Virnes R-E, Tiihonen M, Karttunen N, et al. Opioids and falls risk in older adults: a narrative review. Drugs
Aging. 2022;39(3):199-207. doi:10.1007/s40266-022-00929-y.
https://psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative…
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psnet.ahrq.gov/node/867395/psn-pdf
December 18, 2024 - AHRQ National Healthcare Safety Dashboard.
December 18, 2024
AHRQ National Healthcare Safety Dashboard. National Action Alliance for Patient and Workforce Safety.
https://psnet.ahrq.gov/issue/ahrq-national-healthcare-safety-dashboard
The AHRQ National Healthcare Safety Dashboard is one approach to tracking progress…
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psnet.ahrq.gov/node/43753/psn-pdf
December 10, 2014 - Improving the quality and safety of patient care in cardiac
anesthesia.
December 10, 2014
Merry A, Weller J, Mitchell SJ. Improving the quality and safety of patient care in cardiac anesthesia. J
Cardiothorac Vasc Anesth. 2014;28(5):1341-51. doi:10.1053/j.jvca.2014.02.018.
https://psnet.ahrq.gov/issue/improving-qu…
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psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - Implement strategies to prevent persistent medication
errors and hazards: 2024.
April 3, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack of p…
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psnet.ahrq.gov/node/38200/psn-pdf
November 05, 2008 - Measuring mobile patient safety information system
success: an empirical study.
November 5, 2008
Jen W-Y, Chao C-C. Measuring mobile patient safety information system success: an empirical study. Int J
Med Inform. 2008;77(10):689-97. doi:10.1016/j.ijmedinf.2008.03.003.
https://psnet.ahrq.gov/issue/measuring-mobile…
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psnet.ahrq.gov/node/50594/psn-pdf
October 30, 2019 - Pharmacist linkage in care transitions: from academic
medical center to community.
October 30, 2019
Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic
medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011.
https://psne…
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psnet.ahrq.gov/node/43018/psn-pdf
March 19, 2014 - Improved obstetric safety through programmatic
collaboration.
March 19, 2014
Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration.
J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131.
https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…
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psnet.ahrq.gov/node/44192/psn-pdf
November 10, 2015 - Hospital ratings: a guide for the perplexed.
November 10, 2015
Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2.
doi:10.1001/jama.2015.5269.
https://psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed
Concerns have been raised about the variability of measures used to rate safety a…
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psnet.ahrq.gov/node/45163/psn-pdf
November 30, 2016 - The 2015 John M. Eisenberg Patient Safety and Quality
Awards.
November 30, 2016
Jt Comm J Qual Patient Saf. 2016;42(6):243-264.
https://psnet.ahrq.gov/issue/2015-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
impro…
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psnet.ahrq.gov/node/39110/psn-pdf
June 10, 2018 - Order scanning systems may pull multiple pages through
the scanner at the same time, leading to drug omissions.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.
https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-
leading-dru…
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psnet.ahrq.gov/node/47647/psn-pdf
January 23, 2019 - Patient Safety: Global Action on Patient Safety.
January 23, 2019
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12,
2018.
https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety
This guidance summarizes the current status of global patient safety,…
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psnet.ahrq.gov/node/35704/psn-pdf
March 28, 2011 - Relationship between patient complaints and surgical
complications.
March 28, 2011
Murff HJ, France DJ, Blackford J, et al. Relationship between patient complaints and surgical
complications. Qual Saf Health Care. 2006;15(1):13-6.
https://psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-co…
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psnet.ahrq.gov/node/37276/psn-pdf
December 23, 2011 - Team management training using crisis resource
management results in perceived benefits by healthcare
workers.
December 23, 2011
Rudy SJ, Polomano R, Murray WB, et al. Team management training using crisis resource management
results in perceived benefits by healthcare workers. J Contin Educ Nurs. 2007;38(5):219-2…
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psnet.ahrq.gov/node/866257/psn-pdf
July 25, 2024 - Enhancing Surgical Team Communication: SOPS and
TeamSTEPPS in Action.
July 10, 2024
Agency for Healthcare Research and Quality. July 25, 2024.
https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
Teamwork in the surgical suite is core to safe care but can be challenging to …