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psnet.ahrq.gov/node/43941/psn-pdf
February 25, 2015 - How to make surgery safer.
February 25, 2015
https://psnet.ahrq.gov/issue/how-make-surgery-safer
This newspaper article reports on various ways hospitals are working to make surgical care safer and
reduce readmissions due to surgical complications, including checklists, teamwork training courses for
surgeons, preo…
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psnet.ahrq.gov/node/36387/psn-pdf
July 14, 2010 - Effectiveness of a community collaborative for
eliminating the use of high-risk abbreviations written by
physicians.
July 14, 2010
Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk
Abbreviations Written by Physicians. J Patient Saf. 2008;2(3). doi:10.1097/0…
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psnet.ahrq.gov/node/43748/psn-pdf
December 03, 2014 - New enteral connectors: raising awareness.
December 3, 2014
Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5).
doi:10.1177/0884533614543330.
https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness
Redesigning tubing connectors according to new ISO standards has the potenti…
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psnet.ahrq.gov/node/45990/psn-pdf
August 24, 2022 - Medication Safety Certificate Program.
August 24, 2022
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/medication-safety-certificate-program
Leadership commitment to reduce medication errors can help address this safety problem. This certificate
…
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psnet.ahrq.gov/node/46596/psn-pdf
November 01, 2017 - Infection prevention and control in pediatric ambulatory
settings.
November 1, 2017
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
Patient safety in the ambulatory environme…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/42160/psn-pdf
April 03, 2013 - The perianesthesia nurse's role in the prevention of
opioid-related sentinel events.
April 3, 2013
Pasero C. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. J Perianesth
Nurs. 2013;28(1):31-7. doi:10.1016/j.jopan.2012.11.001.
https://psnet.ahrq.gov/issue/perianesthesia-nurses-r…
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psnet.ahrq.gov/node/45462/psn-pdf
August 31, 2016 - Learning From Mistakes.
August 31, 2016
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
https://psnet.ahrq.gov/issue/learning-mistakes
The National Health Service (NHS) has a history of sharing analyses of problems in its system.
Summarizing an NHS investigation into the…
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psnet.ahrq.gov/node/41623/psn-pdf
April 05, 2013 - Preventing patient harms through systems of care.
April 5, 2013
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70.
doi:10.1001/jama.2012.9537.
https://psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
Recent initiatives, such as the Partnership for…
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psnet.ahrq.gov/node/45237/psn-pdf
June 15, 2016 - Medication reconciliation in oncological patients: a
randomized clinical trial.
June 15, 2016
Vega TG-C, Sierra-Sánchez JF, Martínez-Bautista MJ, et al. Medication Reconciliation in Oncological
Patients: A Randomized Clinical Trial. J Manag Care Spec Pharm. 2016;22(6):734-40.
doi:10.18553/jmcp.2016.15248.
https:/…
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psnet.ahrq.gov/node/40204/psn-pdf
April 14, 2011 - Residents' intentions and actions after patient safety
education.
April 14, 2011
Jansma JD, Wagner C, Bijnen AB. Residents' intentions and actions after patient safety education. BMC
Health Serv Res. 2010;10:350. doi:10.1186/1472-6963-10-350.
https://psnet.ahrq.gov/issue/residents-intentions-and-actions-after-pati…
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psnet.ahrq.gov/node/37080/psn-pdf
October 03, 2011 - Pharmacists' perceptions of computerized prescriber-
order-entry systems.
October 3, 2011
Inquilla CC, Szeinbach S, Seoane-Vazquez E, et al. Pharmacists' perceptions of computerized prescriber-
order-entry systems. Am J Health Syst Pharm. 2007;64(15):1626-32.
https://psnet.ahrq.gov/issue/pharmacists-perceptions-co…
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psnet.ahrq.gov/node/836788/psn-pdf
March 23, 2022 - A widow’s mission to change NC dental sedation rules.
March 23, 2022
Blythe A. NC Health News. March 10, 2022
https://psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules
Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication
incident and the lack of …
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psnet.ahrq.gov/node/73480/psn-pdf
December 17, 2024 - Improving Patient Safety with Human Factors Methods.
December 17, 2024
Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025.
https://psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
Human factors engineering (HFE) is a primary strategy for advancing safety in healt…
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psnet.ahrq.gov/node/40403/psn-pdf
August 25, 2011 - The quality and economic impact of disruptive behaviors
on clinical outcomes of patient care.
August 25, 2011
Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient
care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/1062860611400592.
https://psnet.ahrq.gov/issue/qual…
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www.ahrq.gov/antibiotic-use/long-term-care/improve/collection.html
June 01, 2021 - Appropriate Collection of Microbiological Specimens
After viewing or presenting this presentation viewers will be able to—
Recognize that collecting a good specimen is important to making treatment decisions.
Detail procedures for collecting urine and respiratory samples from nursing home residents.
…
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psnet.ahrq.gov/node/45544/psn-pdf
December 19, 2016 - Prescribing errors that cause harm.
December 19, 2016
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
https://psnet.ahrq.gov/issue/prescribing-errors-cause-harm
Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year
period, t…
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psnet.ahrq.gov/node/40502/psn-pdf
January 01, 2020 - New 2012 National Patient Safety Goal - catheter-
associated urinary tract infection (CAUTI).
June 1, 2011
Joint Commission.
https://psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract-
infection-cauti
This announcement reveals the new National Patient Safety Goal for 2012…
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psnet.ahrq.gov/node/60262/psn-pdf
April 22, 2020 - COVID-19 exposes potential gaps in PPE training,
effectiveness.
April 22, 2020
Ault A. Medscape Medical News. April 6, 2020.
https://psnet.ahrq.gov/issue/covid-19-exposes-potential-gaps-ppe-training-effectiveness
Training is essential to ensure the safe use of equipment. This article discusses how the incorrect us…
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psnet.ahrq.gov/node/867772/psn-pdf
September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocl.
September 1, 2013
Agency for Healthcare Research and Quality. Universal ICU Decolonization: An Enhanced Protocol.
https://psnet.ahrq.gov/issue/universal-icu-decolonization-enhanced-protocl
Methicillin-resistant?Staphylococcus aureus (MRSA) is a known threat to pati…