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psnet.ahrq.gov/node/41833/psn-pdf
November 14, 2012 - Risks related to patient bed safety.
November 14, 2012
Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual.
2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b.
https://psnet.ahrq.gov/issue/risks-related-patient-bed-safety
Reviewing the three major contributing factors to me…
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psnet.ahrq.gov/node/841489/psn-pdf
December 14, 2022 - Rise to Health Coalition.
December 14, 2022
Boston, MA; Institute for Healthcare Improvement: December 2022.
https://psnet.ahrq.gov/issue/rise-health-coalition
Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative
for collective work to address four areas of e…
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psnet.ahrq.gov/node/43145/psn-pdf
June 15, 2014 - The 2013 John M. Eisenberg Patient Safety and Quality
Awards.
June 15, 2014
Jt Comm J Qual Patient Saf. 2014;40(5):195-218.
https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2013 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/42297/psn-pdf
August 01, 2024 - Society to Improve Diagnosis in Medicine.
August 1, 2024
https://psnet.ahrq.gov/issue/society-improve-diagnosis-medicine
The Society to Improve Diagnosis in Medicine (SIDM) was a not-for-profit organization founded in 2011 that
promoted reducing diagnostic errors through collaboration, research, and education. SIDM…
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psnet.ahrq.gov/node/46442/psn-pdf
October 04, 2017 - Handoff Communication.
October 4, 2017
APSF Newsletter. October 2017;32:29-56.
https://psnet.ahrq.gov/issue/handoff-communication
Handoff processes are known to carry risks of communication errors. This special issue focuses on
transfers involving anesthesia care. Articles review different types of handoffs, chara…
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psnet.ahrq.gov/node/39464/psn-pdf
February 17, 2011 - Evaluation of a redesign initiative in an internal-medicine
residency.
February 17, 2011
McMahon GT, Katz JT, Thorndike ME, et al. Evaluation of a redesign initiative in an internal-medicine
residency. N Engl J Med. 2010;362(14):1304-1311. doi:10.1056/NEJMsa0908136.
https://psnet.ahrq.gov/issue/evaluation-redesign…
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psnet.ahrq.gov/node/41063/psn-pdf
January 27, 2012 - Perspective: ten thousand hours to patient safety, sooner
or later.
January 27, 2012
Pellegrini VD. Perspective: ten thousand hours to patient safety, sooner or later. Acad Med.
2012;87(2):164-7. doi:10.1097/ACM.0b013e31823f7202.
https://psnet.ahrq.gov/issue/perspective-ten-thousand-hours-patient-safety-sooner-or-…
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psnet.ahrq.gov/node/41758/psn-pdf
October 10, 2012 - The Broselow tape as an effective medication dosing
instrument: a review of the literature.
October 10, 2012
Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review
of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.pedn.2012.04.009.
https://psnet.ah…
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psnet.ahrq.gov/node/40212/psn-pdf
April 04, 2011 - Creating effective quality-improvement collaboratives: a
multiple case study.
April 4, 2011
Strating MMH, Nieboer AP, Zuiderent-Jerak T, et al. Creating effective quality-improvement collaboratives:
a multiple case study. BMJ Qual Saf. 2011;20(4). doi:10.1136/bmjqs.2010.047159.
https://psnet.ahrq.gov/issue/creatin…
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psnet.ahrq.gov/node/37243/psn-pdf
December 16, 2011 - Raising the awareness of inpatient nursing staff about
medication errors.
December 16, 2011
Elnour AA, Ellahham NH, Qassas HIA. Raising the awareness of inpatient nursing staff about medication
errors. Pharm World Sci. 2008;30(2):182-90.
https://psnet.ahrq.gov/issue/raising-awareness-inpatient-nursing-staff-about-…
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psnet.ahrq.gov/node/36388/psn-pdf
June 12, 2013 - Using patient safety science to explore strategies for
improving safety in intravenous medication
administration.
June 12, 2013
Franklin M. Journal of the Association for Vascular Access. 2006. 11(3):157–160.
https://psnet.ahrq.gov/issue/using-patient-safety-science-explore-strategies-improving-safety-intravenous-…
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psnet.ahrq.gov/node/34617/psn-pdf
March 07, 2005 - World Alliance for Patient Safety: forward programme.
March 7, 2005
Geneva, Switzerland: World Health Organization; 2004.
https://psnet.ahrq.gov/issue/world-alliance-patient-safety-forward-programme
This report outlines the six goals set by the new world alliance to achieve what no single country could
accomplish …
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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - This strategy not only
reduces unnecessary patient visits and unnecessary patient monitoring and socially
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psnet.ahrq.gov/node/45932/psn-pdf
May 18, 2017 - Polypharmacy.
May 18, 2017
Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.
https://psnet.ahrq.gov/issue/polypharmacy
Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this
special issue explore polypharmacy in a variety of care settings and provide tactics f…
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psnet.ahrq.gov/node/48190/psn-pdf
June 17, 2024 - APSF Stoelting Conference.
June 17, 2024
Anesthesia Patient Safety Foundation. Markell Conference Center, Somerville, MA, September 4–5, 2024.
https://psnet.ahrq.gov/issue/apsf-stoelting-conference
Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference explored
topics related…
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psnet.ahrq.gov/node/36810/psn-pdf
November 19, 2014 - A Systems Approach to Quality Improvement in Long-
Term Care: Safe Medication Practices Workbook.
November 19, 2014
Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care
Foundation. Boston, MA: Commonwealth of Massachusetts; 2008.
https://psnet.ahrq.gov/issue/systems-ap…
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psnet.ahrq.gov/node/38822/psn-pdf
July 29, 2009 - The 5th anniversary of the "Universal Protocol": pitfalls
and pearls revisited.
July 29, 2009
Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls
revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14.
https://psnet.ahrq.gov/issue/5th-annivers…
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psnet.ahrq.gov/node/38530/psn-pdf
April 01, 2009 - Assessing the impact of an educational program on
decreasing prescribing errors at a university hospital.
April 1, 2009
Peeters MJ, Pinto SL. Assessing the impact of an educational program on decreasing prescribing errors at
a university hospital. J Hosp Med. 2009;4(2):97-101. doi:10.1002/jhm.387.
https://psnet.ah…
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psnet.ahrq.gov/node/47348/psn-pdf
September 05, 2018 - Hospital-Acquired Condition Reduction Program
(HACRP).
September 5, 2018
QualityNet. Centers for Medicare and Medicaid Services.
https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate
…
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psnet.ahrq.gov/node/48026/psn-pdf
July 10, 2019 - Network of Patient Safety Databases.
July 10, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/network-patient-safety-databases
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety
incident data to track concerns and reduce risks. Thi…