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psnet.ahrq.gov/node/47904/psn-pdf
April 24, 2019 - Air pressure: human factors are the key to a safer flight
environment.
April 24, 2019
Erich J. EMS World. April 2019;48:26-31.
https://psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment
Air transport service combines risks associated with both aviation and prehospital trauma care. Thi…
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psnet.ahrq.gov/node/45549/psn-pdf
October 12, 2016 - Preventing diagnostic errors in primary care.
October 12, 2016
Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32.
https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
The Improving Diagnosis in Health Care report advocated for enhancing patient en…
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psnet.ahrq.gov/node/73256/psn-pdf
May 12, 2021 - Addiction treatment providers in Pa. face little state
scrutiny despite harm to clients.
May 12, 2021
Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
Systemic oversight weaknesses and lack of…
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psnet.ahrq.gov/node/39265/psn-pdf
February 03, 2010 - Intensive care unit alarms—how many do we need?
February 3, 2010
Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med.
2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888.
https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need
This study found that …
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psnet.ahrq.gov/node/45048/psn-pdf
April 13, 2016 - Do not let "Depo-" medications be a depot for mistakes.
April 13, 2016
ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.
https://psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
Confusion due to look-alike and sound-alike medications are known to contribute to medication err…
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psnet.ahrq.gov/node/43331/psn-pdf
July 09, 2014 - Open wide: looking into the safety culture of dental
school clinics.
July 9, 2014
Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J
Dent Edu. 2014;78(5):745-756.
https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics
Researche…
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psnet.ahrq.gov/node/74756/psn-pdf
February 09, 2022 - Medication errors in overweight and obese pediatric
patients: a systematic review.
February 9, 2022
Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a
systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005.
https://psnet…
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psnet.ahrq.gov/node/851059/psn-pdf
June 28, 2023 - Causes for medical errors in obstetrics and gynaecology.
June 28, 2023
Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare
(Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636.
https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
R…
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psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/842431/psn-pdf
January 11, 2023 - Confronting racism in pediatric care.
January 11, 2023
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685.
doi:10.1377/hlthaff.2022.01157.
https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care
Racism is a patient safety issue that is gaining the increased attention ne…
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psnet.ahrq.gov/node/37117/psn-pdf
October 04, 2011 - Language barriers to prescriptions for patients with
limited English proficiency: a survey of pharmacies.
October 4, 2011
Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited
English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225-35.
https://psnet.a…
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psnet.ahrq.gov/node/41826/psn-pdf
June 03, 2013 - Effects of an enhanced discharge planning intervention
for hospitalized older adults: a randomized trial.
June 3, 2013
Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for
hospitalized older adults: a randomized trial. Gerontologist. 2013;53(3):430-40. doi:10.1093/geront…
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psnet.ahrq.gov/node/45586/psn-pdf
November 02, 2016 - Antimicrobial stewardship and patient safety.
November 2, 2016
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356.
doi:10.1016/j.aorn.2016.08.002.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
Antimicrobial stewardship has been highlighted as a strate…
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psnet.ahrq.gov/node/47792/psn-pdf
May 01, 2019 - New evidence on stemming low-value prescribing.
May 1, 2019
Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019.
https://psnet.ahrq.gov/issue/new-evidence-stemming-low-value-prescribing
Overprescribing contributes to polypharmacy, antibiotic resistance, and opioid misuse. This commentary
discusses stra…
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psnet.ahrq.gov/node/74276/psn-pdf
January 19, 2022 - Guideline for Prevention of Unintentionally Retained
Surgical Items.
January 19, 2022
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6.
doi:10.1002/aorn.13579.
https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
Retained su…
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psnet.ahrq.gov/node/42985/psn-pdf
February 26, 2014 - Confusion—specimen mix-up in dermatopathology and
measures to prevent and detect it.
February 26, 2014
Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it.
Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04.
https://psnet.ahrq.gov/issue/confusion-specimen-mix…
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psnet.ahrq.gov/node/50809/psn-pdf
January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See
What We Mean.
January 15, 2020
MedStar Health National Center for Human Factors in Healthcare.
https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean
Electronic health records (EHR) optimize information functions in c…
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psnet.ahrq.gov/node/45801/psn-pdf
August 03, 2017 - Overcoming diagnostic errors in medical practice.
August 3, 2017
Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr.
2017;185. doi:10.1016/j.jpeds.2017.02.065.
https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice
This commentary describes a progra…
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psnet.ahrq.gov/node/858323/psn-pdf
December 13, 2023 - Some doctors are ditching the scale, saying focusing on
weight drives misdiagnoses.
December 13, 2023
O'Neill E. Health Shots. National Public Radio. December 2, 2023.
https://psnet.ahrq.gov/issue/some-doctors-are-ditching-scale-saying-focusing-weight-drives-misdiagnoses
Inordinate focus on one element o…