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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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psnet.ahrq.gov/node/50771/psn-pdf
May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd
edition.
May 29, 2024
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication
No. 15-0023-EF.
https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
The AHRQ Health Literacy Un…
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psnet.ahrq.gov/node/61002/psn-pdf
September 17, 2020 - Patient Safety
September 17, 2020
Organisation for Economic Co-operation and Development.
https://psnet.ahrq.gov/issue/patient-safety-21
Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error.
This website provides a collection of reports and other resources that c…
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psnet.ahrq.gov/node/42447/psn-pdf
July 24, 2013 - Economic Analysis of Medical Malpractice Liability and Its
Reform.
July 24, 2013
Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No.
13-25.
https://psnet.ahrq.gov/issue/economic-analysis-medical-malpractice-liability-and-its-reform
This report describes a ma…
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psnet.ahrq.gov/node/41075/psn-pdf
January 18, 2012 - Wide heart monitor use tied to missed alarms.
January 18, 2012
Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia
and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest
Standards for Electrocardiography trial. J…
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psnet.ahrq.gov/node/73173/psn-pdf
April 21, 2021 - Racism and Health.
April 21, 2021
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/racism-and-health
Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This
US Centers for Disease Control and Prevention (CDC) initiative provides access to …
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psnet.ahrq.gov/node/37413/psn-pdf
November 14, 2011 - Patient Safety Tools: Improving Safety at the Point of
Care.
November 14, 2011
https://psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care-0
Produced in conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program,
AHRQ has released 17 freely available toolkits to help ho…
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psnet.ahrq.gov/node/45226/psn-pdf
January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in
Health Care.
January 4, 2017
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care
Research is increasingly focusing on diagnostic errors and strategies to reduc…
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psnet.ahrq.gov/node/50667/psn-pdf
November 13, 2019 - Proactive prevention of maternal death from maternal
hemorrhage.
November 13, 2019
Quick Safety. October 29, 2019;(51):1-3.
https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety
…
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psnet.ahrq.gov/node/42975/psn-pdf
February 26, 2014 - State-Wide Initiative to Standardize the Compounding of
Oral Liquids in Pediatrics.
February 26, 2014
Michigan Pharmacists Association; MPA.
https://psnet.ahrq.gov/issue/state-wide-initiative-standardize-compounding-oral-liquids-pediatrics
Children are often prescribed oral liquid medications due to difficulty swa…
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psnet.ahrq.gov/node/43216/psn-pdf
June 25, 2014 - Banning the handshake from the health care setting.
June 25, 2014
Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA.
2014;311(24):2477-8.
https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting
Hand hygiene is an important practice that prevents transmissi…
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psnet.ahrq.gov/node/37788/psn-pdf
May 28, 2008 - Durable improvements in efficiency, safety, and
satisfaction in the operating room.
May 28, 2008
Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the
operating room. J Am Coll Surg. 2008;206(5):1083-9; discussion 1089-90.
doi:10.1016/j.jamcollsurg.2008.02.006.
…
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psnet.ahrq.gov/node/39585/psn-pdf
June 09, 2010 - Bar code technology and medication administration error.
June 9, 2010
Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf.
2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7.
https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
This…
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psnet.ahrq.gov/node/45291/psn-pdf
November 30, 2016 - Just Bag It.
November 30, 2016
National Comprehensive Cancer Network.
https://psnet.ahrq.gov/issue/just-bag-it
Vincristine is a chemotherapy agent that can have serious consequences if administered incorrectly.
Drawing from guidelines and expert opinion regarding vincristine administration, this campaign advocates…
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psnet.ahrq.gov/node/43233/psn-pdf
June 17, 2014 - Quality and safety education for nurses: a nursing
leadership skills exercise.
June 17, 2014
Harrison EM. Quality and safety education for nurses: a nursing leadership skills exercise. J Nurs Educ.
2014;53(6):356-361. doi:10.3928/01484834-20140512-01.
https://psnet.ahrq.gov/issue/quality-and-safety-education-nurse…
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…
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psnet.ahrq.gov/node/44226/psn-pdf
November 03, 2015 - The Patient Survival Handbook.
November 3, 2015
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
https://psnet.ahrq.gov/issue/patient-survival-handbook
Engaging patients in their care is increasingly advocated as a way to improve safety. This book
recommends actions for patients and families to reduce risk…
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psnet.ahrq.gov/node/41506/psn-pdf
October 12, 2012 - Preventable errors in organ transplantation: an emerging
patient safety issue?
October 12, 2012
Ison MG, Holl JL, Ladner D. Preventable errors in organ transplantation: an emerging patient safety issue?
Am J Transplant. 2012;12(9):2307-12. doi:10.1111/j.1600-6143.2012.04139.x.
https://psnet.ahrq.gov/issue/preventa…
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psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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psnet.ahrq.gov/node/44613/psn-pdf
October 28, 2015 - Getting rid of "never events" in hospitals.
October 28, 2015
Morgenthaler T; Harper CM.
https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals
Never events are devastating and preventable, and health care organizations are under increasing
pressure to eliminate them. This commentary discusses how the Mayo…