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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/node/867020/psn-pdf
October 23, 2024 - What can we learn from coroners’ reports on preventable
deaths?
October 23, 2024
Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.
https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
Analysis of system failure is only the beginning of the i…
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psnet.ahrq.gov/node/45679/psn-pdf
January 03, 2018 - Global Guidelines on the Prevention of Surgical Site
Infection.
January 3, 2018
Global Guidelines on the Prevention of Surgical Site Infection.
https://psnet.ahrq.gov/issue/global-guidelines-prevention-surgical-site-infection
Efforts to reduce surgical site infections have achieved some success. The World Health O…
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psnet.ahrq.gov/node/46670/psn-pdf
December 18, 2017 - A narrative review of the safety concerns of deprescribing
in older adults and strategies to mitigate potential harms.
December 18, 2017
Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older
adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2…
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psnet.ahrq.gov/node/43932/psn-pdf
March 04, 2015 - Safety considerations to mitigate the risks of
misconnections with small-bore connectors intended for
enteral applications.
March 4, 2015
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February
11, 2015.
https://psnet.ahrq.gov/issue/safety-considerations-mitigate-risks…
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psnet.ahrq.gov/node/39732/psn-pdf
August 04, 2010 - A comparative resident site visit project: a novel
approach for implementing programmatic change in the
duty hours era.
August 4, 2010
Crowley MJ, Barkauskas CE, Srygley D, et al. A comparative resident site visit project: a novel approach
for implementing programmatic change in the duty hours era. Acad Med. 2010;…
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psnet.ahrq.gov/node/44797/psn-pdf
March 15, 2016 - Incident and error reporting systems in intensive care: a
systematic review of the literature.
March 15, 2016
Brunsveld-Reinders AH, Arbous S, De Vos R, et al. Incident and error reporting systems in intensive care:
a systematic review of the literature. Int J Qual Health Care. 2016;28(1):2-13. doi:10.1093/intqhc/m…
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psnet.ahrq.gov/node/42912/psn-pdf
December 12, 2014 - Mandatory influenza vaccination for health care workers
as the new standard of care: a matter of patient safety and
nonmaleficent practice.
December 12, 2014
Cortes-Penfield N. Mandatory influenza vaccination for health care workers as the new standard of care: a
matter of patient safety and nonmaleficent practice…
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psnet.ahrq.gov/node/852800/psn-pdf
August 23, 2023 - Handling injectable medications in anaesthesia:
Guidelines from the Association of Anaesthetists.
August 23, 2023
Kinsella SM, Boaden B, El?Ghazali S, et al. Handling injectable medications in anaesthesia: Guidelines
from the Association of Anaesthetists. Anaesthesia. 2023;78(10):1285-1294. doi:10.1111/anae.16095.
…
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psnet.ahrq.gov/node/866324/psn-pdf
July 17, 2024 - Total systems safety supports practitioners in partnering
with families to protect patients.
July 17, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4.
https://psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
Patient and family concerns can provide…
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psnet.ahrq.gov/node/36244/psn-pdf
June 13, 2012 - With Safety in Mind: Mental Health Services and Patient
Safety.
June 13, 2012
Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006.
https://psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
This report, the second in a series from the United Kingdom's Nati…
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psnet.ahrq.gov/node/43854/psn-pdf
February 11, 2015 - Medicare’s Oversight of Compounded Pharmaceuticals
Used in Hospitals.
February 11, 2015
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; January 2015. Report No. OEI-01-13-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-compounded-pharmaceuticals-use…
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psnet.ahrq.gov/node/47181/psn-pdf
August 22, 2018 - Critical role of the surgeon–anesthesiologist relationship
for patient safety.
August 22, 2018
Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology.
2018;129(3):402-405. doi:10.1097/ALN.0000000000002324.
https://psnet.ahrq.gov/issue/critical-role-surgeon-anesthes…
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psnet.ahrq.gov/node/73582/psn-pdf
August 11, 2021 - Visual illusions in radiology: untrue perceptions in
medical images and their implications for diagnostic
accuracy.
August 11, 2021
Alexander RG, Yazdanie F, Waite S, et al. Visual illusions in radiology: untrue perceptions in medical
images and their implications for diagnostic accuracy. Front Neurosci. 2021;15:6…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/41763/psn-pdf
October 10, 2012 - Latency of ECG displays of hospital telemetry systems: a
science advisory from the American Heart Association.
October 10, 2012
Turakhia MP, Estes NAM, Drew BJ, et al. Latency of ECG displays of hospital telemetry systems: a science
advisory from the American Heart Association. Circulation. 2012;126(13):1665-9.
ht…
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psnet.ahrq.gov/node/44146/psn-pdf
June 03, 2015 - Transforming communication and safety culture in
intrapartum care: a multi-organization blueprint.
June 3, 2015
Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum
care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049-55.
doi:10.1097/AOG.000000000000…
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psnet.ahrq.gov/node/47410/psn-pdf
April 10, 2019 - Patient–pharmacist communication during a post-
discharge pharmacist home visit.
April 10, 2019
Ensing HT, Vervloet M, van Dooren AA, et al. Patient-pharmacist communication during a post-discharge
pharmacist home visit. Int J Clin Pharm. 2018;40(3):712-720. doi:10.1007/s11096-018-0639-3.
https://psnet.ahrq.gov/is…
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www.ahrq.gov/patient-safety/settings/labor-delivery/index.html
July 01, 2023 - AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units
AHRQ Safety Program for Perinatal Care – I aims to improve the patient safety culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse events resulting from poor communication and system failures.…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction
Introduction
Previous Page Next Page
Table of Contents
Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction
Introduction
Rationale for Use
Content-Specific Versus Process-Focused Checklis…