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psnet.ahrq.gov/issue/recommendations-individualized-medical-treatment-and-common-adverse-events-management-lung
March 24, 2019 - Commentary
Recommendations of individualized medical treatment and common adverse events management for lung cancer patients during the outbreak of COVID-19 epidemic.
Citation Text:
Zhao Z, Bai H, Duan J, et al. Recommendations of individualized medical treatment and common adverse event…
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psnet.ahrq.gov/issue/front-line-staff-perspectives-opportunities-improving-safety-and-efficiency-hospital-work
February 04, 2009 - Study
Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems.
Citation Text:
Tucker AL, Singer SJ, Hayes J, et al. Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. H…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
June 14, 2023 - Study
Learning from patient safety incidents: The Green Cross method.
Citation Text:
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
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DOI Go…
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psnet.ahrq.gov/issue/factors-contributing-registered-nurse-medication-administration-error-narrative-review
May 27, 2011 - Review
Factors contributing to Registered Nurse medication administration error: a narrative review.
Citation Text:
Parry AM, Barriball L, While AE. Factors contributing to registered nurse medication administration error: a narrative review. Int J Nurs Stud. 2015;52(1):403-20. doi:10.10…
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psnet.ahrq.gov/issue/introduction-novel-patient-safety-advisory-evaluation-perceived-information-modified-qpp
April 05, 2023 - Study
Introduction of a novel patient safety advisory: evaluation of perceived information with a modified QPP questionnaire-a case-control study.
Citation Text:
Tubic B, Bånnsgård M, Gustavsson S, et al. Introduction of a novel patient safety advisory: evaluation of perceived informatio…
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psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and-schedule-errors
January 20, 2021 - Study
Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors.
Citation Text:
Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.…
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psnet.ahrq.gov/issue/identifying-barriers-and-enablers-robust-independent-second-check-medication-adult-intensive
March 09, 2016 - Study
Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.
Citation Text:
Milic V, Cameron L, Jones C. Identifying barriers and enablers for a robust independent second check of medication in adult intensive care. Br J Nurs. 2023;…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/50666/psn-pdf
November 13, 2019 - Over-the-top risky: overuse of ADC overrides, removal of
drugs without an order, and use of non-profiled cabinets.
November 13, 2019
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
https://psnet.ahrq.gov/issue/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-
non-profile…
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psnet.ahrq.gov/node/867701/psn-pdf
August 01, 2017 - Toolkit To Improve Safety for Mechanically Ventilated
Patients.
August 1, 2017
Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated
Patients. August 2017.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
Patients requiring mechanica…
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psnet.ahrq.gov/node/45486/psn-pdf
September 14, 2016 - Addressing nurse fatigue to promote safety and health:
joint responsibilities of registered nurses and employers
to reduce risks.
September 14, 2016
Silver Spring, MD: American Nurses Association; September 2014.
https://psnet.ahrq.gov/issue/addressing-nurse-fatigue-promote-safety-and-health-joint-responsibilities…
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psnet.ahrq.gov/node/40385/psn-pdf
May 21, 2019 - A comprehensive obstetrics patient safety program
improves safety climate and culture.
May 21, 2019
Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety
climate and culture. Am J Obstet Gynecol. 2011;204(3):216.e1-6. doi:10.1016/j.ajog.2010.11.004.
https://psnet.a…
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psnet.ahrq.gov/node/867449/psn-pdf
March 13, 2025 - Medication Related Harm.
March 13, 2025
Medication Related Harm. Health Services Safety Investigations Body. 2024-2025
https://psnet.ahrq.gov/issue/medication-related-harm
Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series
of reports, to be developed over 2024…
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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - Governing the safety of artificial intelligence in
healthcare.
May 20, 2019
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498.
doi:10.1136/bmjqs-2019-009484.
https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risk…
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psnet.ahrq.gov/node/72751/psn-pdf
February 17, 2021 - The critical need for nursing education to address the
diagnostic process.
February 17, 2021
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic
process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
https://psnet.ahrq.gov/issue/critica…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/47718/psn-pdf
March 20, 2019 - Impact of patient safety culture on missed nursing care
and adverse patient events.
March 20, 2019
Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and
Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/39597/psn-pdf
July 14, 2010 - Ten strategies to improve management of abnormal test
result alerts in the electronic health record.
July 14, 2010
Singh H, Wilson L, Reis B, et al. Ten strategies to improve management of abnormal test result alerts in the
electronic health record. J Patient Saf. 2010;6(2):121-123. doi:10.1097/PTS.0b013e3181ddf652…
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psnet.ahrq.gov/node/43952/psn-pdf
March 04, 2015 - Improving resident morning sign-out by use of daily
events reports.
March 4, 2015
Nabors C, Patel D, Khera S, et al. Improving resident morning sign-out by use of daily events reports. J
Patient Saf. 2015;11(1):36-41. doi:10.1097/PTS.0b013e31829e4f56.
https://psnet.ahrq.gov/issue/improving-resident-morning-sign-ou…
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psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…