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psnet.ahrq.gov/node/866318/psn-pdf
July 17, 2024 - Methods to increase reliability in quality improvement
projects.
July 17, 2024
Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp
Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340.
https://psnet.ahrq.gov/issue/methods-increase-reliability-quality-…
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psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - Hospital and procedure incidence of pediatric retained
surgical items.
September 9, 2015
Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J
Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054.
https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
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psnet.ahrq.gov/node/34594/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. The Leapfrog
Group for Patient Safety: rewarding higher standards.
January 4, 2017
Eikel C, Delbanco S. John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety:
rewarding higher standards. Jt Comm J Qual Saf. 2003;29(12):634-9.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/45826/psn-pdf
January 18, 2017 - Ensuring staff safety when treating potentially violent
patients.
January 18, 2017
Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA.
2016;316(24):2669-2670. doi:10.1001/jama.2016.18260.
https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…
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psnet.ahrq.gov/node/44123/psn-pdf
July 11, 2018 - The 2014 John M. Eisenberg Patient Safety and Quality
Awards.
July 11, 2018
Jt Comm J Qual Patient Saf. 2015;41(5):195-211.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/44425/psn-pdf
February 24, 2016 - Dangerous doses.
February 24, 2016
Roe S, King K. Chicago Tribune. February 10–13, 2016.
https://psnet.ahrq.gov/issue/dangerous-doses
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age
and use of medications for chronic conditions. This series of news reports d…
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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/46206/psn-pdf
August 02, 2017 - Patient safety in dentistry: development of a candidate
'never event' list for primary care.
August 2, 2017
Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care.
Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/45383/psn-pdf
August 31, 2016 - Case report of a medication error: in the eye of the
beholder.
August 31, 2016
Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore).
2016;95(28):e4186. doi:10.1097/md.0000000000004186.
https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
Look-alike dr…
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psnet.ahrq.gov/node/43997/psn-pdf
August 02, 2015 - Sentinel events, serious reportable events, and root
cause analysis.
August 2, 2015
Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis.
JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672.
https://psnet.ahrq.gov/issue/sentinel-events-serious-re…
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psnet.ahrq.gov/node/44404/psn-pdf
August 26, 2015 - Nurse interrupted: development of a realistic medication
administration simulation for undergraduate nurses.
August 26, 2015
Hayes C, Power T, Davidson PM, et al. Nurse interrupted: Development of a realistic medication
administration simulation for undergraduate nurses. Nurse Educ Today. 2015;35(9):981-6.
doi:10.…
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psnet.ahrq.gov/node/48005/psn-pdf
May 08, 2019 - Why your doctor's white coat can be a threat to your
health.
May 8, 2019
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic
Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…
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psnet.ahrq.gov/node/34978/psn-pdf
June 30, 2011 - Personal digital assistant-based drug information
sources: potential to improve medication safety.
June 30, 2011
Galt K, Rule AM, Houghton B, et al. Personal digital assistant-based drug information sources: potential to
improve medication safety. J Med Libr Assoc. 2005;93(2):229-36.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/73966/psn-pdf
October 13, 2021 - Prescribing errors with low-molecular-weight heparins.
October 13, 2021
Slikkerveer M, van de Plas A, Driessen JHM, et al. Prescribing errors with low-molecular-weight heparins. J
Patient Saf. 2021;17(7):e587-e592. doi:10.1097/pts.0000000000000417.
https://psnet.ahrq.gov/issue/prescribing-errors-low-molecular-weigh…
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psnet.ahrq.gov/node/865974/psn-pdf
May 29, 2024 - Minimizing bias when using artificial intelligence in
critical care medicine.
May 29, 2024
Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J
Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796.
https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
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psnet.ahrq.gov/node/46988/psn-pdf
April 25, 2018 - Opioid Stewardship.
April 25, 2018
Ochsner J. 2018;18(1):20-45.
https://psnet.ahrq.gov/issue/opioid-stewardship
Both organizational and national strategies are required to reduce opioid-related harm. This special issue
section explores one health system's efforts to address the opioid epidemic. Articles discuss em…
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psnet.ahrq.gov/node/867686/psn-pdf
March 05, 2025 - Association between surgeon stress and major surgical
complications.
March 5, 2025
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications.
JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
https://psnet.ahrq.gov/issue/association-between-surgeon-stre…
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psnet.ahrq.gov/node/48045/psn-pdf
June 05, 2019 - Obstetric practice guidelines: labor's love lost?
June 5, 2019
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med.
2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
Guidelines play a…
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psnet.ahrq.gov/node/34062/psn-pdf
February 18, 2011 - Adverse drug events in ambulatory care.
February 18, 2011
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. New Engl J Med.
2003;348(16):1556-1564.
https://psnet.ahrq.gov/issue/adverse-drug-events-ambulatory-care
This prospective cohort study evaluated more than 1200 outpatient prescr…