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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
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psnet.ahrq.gov/node/37336/psn-pdf
January 05, 2012 - 'My five moments for hand hygiene': a user-centred
design approach to understand, train, monitor and report
hand hygiene.
January 5, 2012
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to
understand, train, monitor and report hand hygiene. J Hosp Infect. 200…
-
psnet.ahrq.gov/node/74186/psn-pdf
January 01, 2022 - Staffing, teamwork and scope of practice: analysis of the
association with patient safety in the context of
rehabilitation.
December 15, 2021
Jomaa C, Dubois C?A, Caron I, et al. Staffing, teamwork and scope of practice: analysis of the association
with patient safety in the context of rehabilitation. J Adv Nurs. …
-
psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
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psnet.ahrq.gov/node/45010/psn-pdf
March 30, 2016 - Most dangerous time at the hospital? It may be when you
leave.
March 30, 2016
Khullar D. New York Times. March 17, 2016.
https://psnet.ahrq.gov/issue/most-dangerous-time-hospital-it-may-be-when-you-leave
Preventing readmissions after hospital discharge is a national policy priority. This newspaper article
discuss…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/851204/psn-pdf
July 05, 2023 - Drugmakers are abandoning cheap generics, and now US
cancer patients can’t get meds.
July 5, 2023
Allen A. KFF Health News. June 21, 2023.
https://psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients-
cant-get-meds
A variety of supply-chain, quality control, and economic factor…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/837695/psn-pdf
July 20, 2022 - Narrowing the mindware gap in medicine.
July 20, 2022
Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183.
doi:10.1515/dx-2020-0128.
https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine
In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…
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psnet.ahrq.gov/node/45866/psn-pdf
March 08, 2017 - Medication safety in the neonatal intensive care unit: big
measures for our smallest patients.
March 8, 2017
Rostas SE. Medication Safety in the Neonatal Intensive Care Unit: Big Measures for Our Smallest Patients.
J Perinat Neonatal Nurs. 2017;31(1):15-19. doi:10.1097/JPN.0000000000000230.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/74011/psn-pdf
October 27, 2021 - Dashboards for visual display of patient safety data: a
systematic review.
October 27, 2021
Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic
review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437.
https://psnet.ahrq.gov/issue/dash…
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psnet.ahrq.gov/node/43307/psn-pdf
September 26, 2016 - Mitigating errors caused by interruptions during
medication verification and administration: interventions
in a simulated ambulatory chemotherapy setting.
September 26, 2016
Prakash V, Koczmara C, Savage P, et al. Mitigating errors caused by interruptions during medication
verification and administration: interven…
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psnet.ahrq.gov/node/42397/psn-pdf
September 05, 2013 - Impact of the World Health Organization's Surgical Safety
Checklist on safety culture in the operating theatre: a
controlled intervention study.
September 5, 2013
Haugen AS, Søfteland E, Eide GE, et al. Impact of the World Health Organization's Surgical Safety
Checklist on safety culture in the operating theatre: …
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psnet.ahrq.gov/node/46640/psn-pdf
August 08, 2018 - IDEA4PS: the development of a research-oriented
learning healthcare system.
August 8, 2018
Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented
Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.
https://psnet.ahrq.gov/issue/idea4ps-…
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psnet.ahrq.gov/node/48005/psn-pdf
May 08, 2019 - Why your doctor's white coat can be a threat to your
health.
May 8, 2019
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic
Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…
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psnet.ahrq.gov/node/45469/psn-pdf
January 18, 2017 - Tamper-resistant drugs cannot solve the opioid crisis.
January 18, 2017
Leece P, Orkin AM, Kahan M. Tamper-resistant drugs cannot solve the opioid crisis. CMAJ.
2015;187(10):717-718. doi:10.1503/cmaj.150329.
https://psnet.ahrq.gov/issue/tamper-resistant-drugs-cannot-solve-opioid-crisis
Health care organizations ha…
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psnet.ahrq.gov/node/47681/psn-pdf
January 30, 2019 - Infection prevention in the operating room anesthesia
work area.
January 30, 2019
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work
area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
https://psnet.ahrq.gov/issue/infection-prevention-operat…
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psnet.ahrq.gov/node/46776/psn-pdf
February 28, 2018 - Older adults' awareness of deprescribing: a population-
based survey.
February 28, 2018
Turner JP, Tannenbaum C. Older adults' awareness of deprescribing: a population-based survey. J Am
Geriatr Soc. 2017;65(12):2691-2696. doi:10.1111/jgs.15079.
https://psnet.ahrq.gov/issue/older-adults-awareness-deprescribing-pop…