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psnet.ahrq.gov/node/46630/psn-pdf
November 15, 2017 - Patient Safety in the Office-Based Practice Setting.
November 15, 2017
Philadelphia, PA: American College of Physicians; 2017.
https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy.
Th…
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psnet.ahrq.gov/node/843095/psn-pdf
January 25, 2023 - Eliminating racial and ethnic disparities causing mortality
and morbidity in pregnant and postpartum patients.
January 25, 2023
Sentinel Event Alert. January 17, 2023:(66):1-5.
https://psnet.ahrq.gov/issue/eliminating-racial-and-ethnic-disparities-causing-mortality-and-morbidity-
pregnant-and
Racial and ethnic in…
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psnet.ahrq.gov/node/73477/psn-pdf
July 07, 2021 - Closing Death’s Door: Legal Innovations to End the
Epidemic of Healthcare Harm.
July 7, 2021
Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
https://psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
A weave of systemic factors c…
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psnet.ahrq.gov/node/35836/psn-pdf
March 28, 2011 - Use of a standardized protocol to decrease medication
errors and adverse events related to sliding scale insulin.
March 28, 2011
Donihi AC, DiNardo MM, Devita MA, et al. Use of a standardized protocol to decrease medication errors
and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2)…
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psnet.ahrq.gov/node/45572/psn-pdf
March 22, 2017 - Ordering interruptions in a tertiary care center: a
prospective observational study.
March 22, 2017
Dadlez NM, Azzarone G, Sinnett MJ, et al. Ordering Interruptions in a Tertiary Care Center: A Prospective
Observational Study. Hosp Pediatr. 2017;7(3):134-139. doi:10.1542/hpeds.2016-0127.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44152/psn-pdf
November 06, 2015 - Infection Prevention.
November 6, 2015
Allen G, ed. AORN J. 2015;101:505-596.
https://psnet.ahrq.gov/issue/infection-prevention
A primary concern in the perioperative setting is the prevention of health care–associated infections,
particularly surgical site infections. Articles in this special issue explore strate…
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psnet.ahrq.gov/node/60656/psn-pdf
July 08, 2020 - COVID-19: to be or not to be; that is the diagnostic
question.
July 8, 2020
Coleman JJ, Manavi K, Marson EJ, et al. COVID-19: to be or not to be; that is the diagnostic question.
Postgrad Med J. 2020;96(1137):392-398. doi:10.1136/postgradmedj-2020-137979.
https://psnet.ahrq.gov/issue/covid-19-be-or-not-be-diagnost…
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psnet.ahrq.gov/node/43120/psn-pdf
September 27, 2016 - How studying human factors improves patient safety.
September 27, 2016
Eggertson L. How studying human factors improves patient safety. The Canadian nurse. 2014;110(2):25-9.
https://psnet.ahrq.gov/issue/how-studying-human-factors-improves-patient-safety
Human factors engineering is being increasingly promoted as an…
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psnet.ahrq.gov/node/837861/psn-pdf
August 17, 2022 - Skin cancer is a risk no matter the skin tone. But it may
be overlooked in people with dark skin.
August 17, 2022
West S. Kaiser Health News. August 5, 2022.
https://psnet.ahrq.gov/issue/skin-cancer-risk-no-matter-skin-tone-it-may-be-overlooked-people-dark-skin
The article highlights skin cancer identification pro…
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psnet.ahrq.gov/node/44617/psn-pdf
January 22, 2016 - Pediatric prehospital medication dosing errors: a mixed-
methods study.
January 22, 2016
Hoyle JD, Sleight D, Henry R, et al. Pediatric prehospital medication dosing errors: a mixed-methods study.
Prehosp Emerg Care. 2016;20(1):117-124. doi:10.3109/10903127.2015.1061625.
https://psnet.ahrq.gov/issue/pediatric-preh…
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psnet.ahrq.gov/node/50387/psn-pdf
September 25, 2019 - Special Issue on Prescription Drug Misuse.
September 25, 2019
Rickles NM, Fleming ML, Björnsdottir I, eds. Res Social Adm Pharm. 2019;15:907-1056.
https://psnet.ahrq.gov/issue/special-issue-prescription-drug-misuse
This special issue reviews research initiatives exploring persistent challenges associated with the
…
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psnet.ahrq.gov/node/48111/psn-pdf
July 10, 2019 - Medication Safety in Key Action Areas.
July 10, 2019
Geneva, Switzerland: World Health Organization; 2019.
https://psnet.ahrq.gov/issue/medication-safety-key-action-areas
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores
key areas of concern that require act…
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psnet.ahrq.gov/node/36576/psn-pdf
January 14, 2011 - Need for standardized sign-out in the emergency
department: a survey of emergency medicine residency
and pediatric emergency medicine fellowship program
directors.
January 14, 2011
Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey
of emergency medicine resid…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/node/43874/psn-pdf
February 25, 2015 - An overview of the use and implementation of checklists
in surgical specialities - a systematic review.
February 25, 2015
Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical
specialities - a systematic review. Int J Surg. 2014;12(12):1317-23. doi:10.1016/j.ijsu.2014…
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psnet.ahrq.gov/node/44531/psn-pdf
September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for
Patients.
September 30, 2015
Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN:
9781460666180.
https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
The never events list was dev…
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psnet.ahrq.gov/node/838638/psn-pdf
September 01, 2012 - Directed peer review in surgical pathology.
September 1, 2012
Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337.
doi:10.1097/pap.0b013e31826661b7.
https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
Diagnostic error in pathology can result in delaye…
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psnet.ahrq.gov/node/41976/psn-pdf
March 11, 2013 - Moving beyond readmission penalties: creating an ideal
process to improve transitional care.
March 11, 2013
Burke RE, Kripalani S, Vasilevskis EE, et al. Moving beyond readmission penalties: creating an ideal
process to improve transitional care. J Hosp Med. 2013;8(2):102-9. doi:10.1002/jhm.1990.
https://psnet.ahr…
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psnet.ahrq.gov/node/39166/psn-pdf
December 09, 2009 - Effectiveness of a pharmacist–nurse intervention on
resolving medication discrepancies for patients
transitioning from hospital to home health care.
December 9, 2009
Setter SM, Corbett CF, Neumiller JJ, et al. Effectiveness of a pharmacist-nurse intervention on resolving
medication discrepancies for patients trans…
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psnet.ahrq.gov/node/47994/psn-pdf
July 16, 2019 - What's in a name? Newborn naming conventions and
wrong-patient errors.
July 16, 2019
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
https://psnet.ahrq.gov/issue/whats-name-newborn-naming-conventions-and-wrong-patient-errors
Newborns assigned temporary names are at increased risk for patient misi…