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psnet.ahrq.gov/node/45334/psn-pdf
September 07, 2016 - Why 'Universal Precautions' are needed for medication
lists.
September 7, 2016
Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2.
doi:10.1136/bmjqs-2015-005116.
https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists
Despite the support…
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psnet.ahrq.gov/node/44602/psn-pdf
November 25, 2015 - Interorganizational complexity and organizational
accident risk: a literature review.
November 25, 2015
Milch V, Laumann K. Interorganizational complexity and organizational accident risk: A literature review.
Safety Sci. 2015;82:9-17. doi:10.1016/j.ssci.2015.08.010.
https://psnet.ahrq.gov/issue/interorganizationa…
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psnet.ahrq.gov/node/35387/psn-pdf
September 10, 2009 - A human factors engineering conceptual framework of
nursing workload and patient safety in intensive care
units.
September 10, 2009
Carayon P, Gurses AP. A human factors engineering conceptual framework of nursing workload and
patient safety in intensive care units. Intensive Crit Care Nurs. 2005;21(5):284-301.
h…
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psnet.ahrq.gov/node/35628/psn-pdf
June 23, 2010 - Medical professional liability insurance and its relation to
medical error and healthcare risk management for the
practicing physician.
June 23, 2010
Abbott RL, Weber P, Kelley B. Medical professional liability insurance and its relation to medical error and
healthcare risk management for the practicing physician.…
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psnet.ahrq.gov/node/46593/psn-pdf
November 08, 2017 - Unreadable barcodes and multiple barcodes on packages
can lead to errors.
November 8, 2017
ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3.
https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors
Barcodes can both enhance and degrade the medication …
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psnet.ahrq.gov/node/839830/psn-pdf
November 09, 2022 - Walgreens will stop judging its pharmacy staffers by how
fast they work.
November 9, 2022
Kaplan A. NBC News. October 27, 2022.
https://psnet.ahrq.gov/issue/walgreens-will-stop-judging-its-pharmacy-staffers-how-fast-they-work
Suboptimal working conditions are a known contributor to errors in retail pharmacie…
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psnet.ahrq.gov/node/43415/psn-pdf
September 10, 2014 - Project BOOST implementation: lessons learned.
September 10, 2014
Williams M, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J.
2014;107(7):455-65. doi:10.14423/SMJ.0000000000000140.
https://psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned
This qualitative study o…
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psnet.ahrq.gov/node/41510/psn-pdf
July 11, 2012 - Dangerous connections: health care community tackles
tubing risks, small-bore connector standards.
July 11, 2012
Vockley M. Joint Commission: The Source. June 2012;10:15-17.
https://psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small-
bore-connector
This newsletter article …
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psnet.ahrq.gov/node/73101/psn-pdf
April 07, 2021 - Do No Harm: Are We Preventing Medication Errors in
Children with Medical Complexity?
March 31, 2021
Children's Healthcare Canada. April 7, 2021.
https://psnet.ahrq.gov/issue/do-no-harm-are-we-preventing-medication-errors-children-medical-complexity
Children are particularly vulnerable to medication errors. This se…
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psnet.ahrq.gov/node/43562/psn-pdf
September 24, 2014 - What's that sound? Managing alarm fatigue.
September 24, 2014
George TP, Martin V. What?s that sound? Managing alarm fatigue. Nursing Made Incredibly Easy!.
2014;12(5). doi:10.1097/01.nme.0000452689.19763.3f.
https://psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
Alarm fatigue has been described as a cont…
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psnet.ahrq.gov/node/43100/psn-pdf
April 02, 2014 - Taking National Action to Prevent and Eliminate
Healthcare-Associated Infections.
April 2, 2014
Kahn KL, Battles JB, eds. Med Care. 2014;52:i-ii,s1-s100.
https://psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
This special issue explores a national initiativ…
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psnet.ahrq.gov/node/73669/psn-pdf
September 01, 2021 - Infection Prevention Compendium For Long-Term Care
Facilities.
September 1, 2021
Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.
https://psnet.ahrq.gov/issue/infection-prevention-compendium-long-term-care-facilities
Healthcare-associated infections (HAIs) challenge safety in long-te…
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psnet.ahrq.gov/node/37938/psn-pdf
July 23, 2008 - An integrative review of the current evidence on the
relationship between hand hygiene interventions and the
incidence of health care-associated infections.
July 23, 2008
Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship
between hand hygiene interventions and the in…
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psnet.ahrq.gov/node/837798/psn-pdf
August 10, 2022 - An evolution of reporting: identifying the missing link.
August 10, 2022
Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics
(Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761.
https://psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link…
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psnet.ahrq.gov/node/48179/psn-pdf
August 21, 2019 - Is WHO's surgical safety checklist being hyped?
August 21, 2019
Urbach DR, Dimick JB, Haynes AB, et al. Is WHO's surgical safety checklist being hyped? BMJ.
2019;366:l4700. doi:10.1136/bmj.l4700.
https://psnet.ahrq.gov/issue/whos-surgical-safety-checklist-being-hyped
Checklists are a popular yet controversial stra…
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psnet.ahrq.gov/node/41946/psn-pdf
January 09, 2013 - Thirty-day outcomes support implementation of a surgical
safety checklist.
January 9, 2013
Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical
safety checklist. J Am Coll Surg. 2012;215(6):766-76. doi:10.1016/j.jamcollsurg.2012.07.015.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/41156/psn-pdf
March 02, 2012 - The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction.
March 2, 2012
Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…
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psnet.ahrq.gov/node/60903/psn-pdf
March 15, 2023 - AMA Prior Authorization (PA) Physician Survey.
March 15, 2023
Chicago, IL: American Medical Association; March 2023.
https://psnet.ahrq.gov/issue/2019-ama-prior-authorization-pa-physician-survey
Insurance policies can have consequences that reduce the safety of medical care. This latest version of the
study …
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psnet.ahrq.gov/node/44269/psn-pdf
July 01, 2015 - Accidental overdoses involving fluorouracil infusions.
July 1, 2015
ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.
https://psnet.ahrq.gov/issue/accidental-overdoses-involving-fluorouracil-infusions
Describing three accidental overdoses of the antineoplastic drug fluorouracil which involved …
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psnet.ahrq.gov/node/41625/psn-pdf
December 02, 2014 - Effects of CPOE on provider cognitive workload: a
randomized crossover trial.
December 2, 2014
Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial.
Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408.
https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…