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psnet.ahrq.gov/node/47160/psn-pdf
August 08, 2018 - Preventing dispensing errors by alerting for drug
confusions in the pharmacy information system—a
survey of users.
August 8, 2018
Campmans Z, van Rhijn A, Dull RM, et al. Preventing dispensing errors by alerting for drug confusions in
the pharmacy information system-A survey of users. PLoS One. 2018;13(5):e0197469…
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psnet.ahrq.gov/node/74169/psn-pdf
December 08, 2021 - Pointing fingers: verbosity of patient safety narratives is
associated with attribution of blame.
December 8, 2021
Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.
https://psnet.ahrq.gov/issue/pointing-fingers-verbosity-patient-safety-narratives-associated-attribution-
bl…
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psnet.ahrq.gov/node/837801/psn-pdf
August 10, 2022 - Decreasing misdiagnoses of urinary tract infections in a
pediatric emergency department.
August 10, 2022
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric
emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/peds.2021-055866.
https://psnet.ah…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/46249/psn-pdf
July 12, 2017 - Zero preventable deaths after traumatic injury: an
achievable goal.
July 12, 2017
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8.
doi:10.1097/ta.0000000000001425.
https://psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
Criti…
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psnet.ahrq.gov/node/866746/psn-pdf
September 18, 2024 - Looking beyond LinkedIn: the case for excellence and
academic rigor in quality and safety programs.
September 18, 2024
Bearman G, Nori P. Looking beyond LinkedIn: the case for excellence and academic rigor in quality and
safety programs. Am J Med. 2024;137(8):694-697. doi:10.1016/j.amjmed.2024.04.018.
https://psne…
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psnet.ahrq.gov/node/866311/psn-pdf
January 01, 2025 - Systematic review of types of safety incidents and the
processes and systems used for safety incident reporting
in care homes.
July 17, 2024
Scott J, Sykes K, Waring J, et al. Systematic review of types of safety incidents and the processes and
systems used for safety incident reporting in care homes. J Adv Nurs. …
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psnet.ahrq.gov/node/35762/psn-pdf
January 02, 2017 - Using Failure Mode and Effects Analysis for safe
administration of chemotherapy to hospitalized children
with cancer.
January 2, 2017
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of
chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/862984/psn-pdf
February 21, 2024 - Machine learning in medication prescription: a systematic
review.
February 21, 2024
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J
Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
https://psnet.ahrq.gov/issue/machine-learning-medication-…
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psnet.ahrq.gov/node/46577/psn-pdf
April 03, 2018 - The new diagnostic team.
April 3, 2018
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238.
doi:10.1515/dx-2017-0022.
https://psnet.ahrq.gov/issue/new-diagnostic-team
Teamwork has been highlighted as a key component of patient safety that also applies to improving
diag…
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/39277/psn-pdf
August 22, 2018 - Preventing maternal death.
August 22, 2018
Preventing maternal death. Sentinel Event Alert. 2010;44(44):1-4.
https://psnet.ahrq.gov/issue/preventing-maternal-death
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid
adoption of risk reduction strategies. Adher…
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psnet.ahrq.gov/node/46907/psn-pdf
April 11, 2018 - To combat physician burnout and improve care, fix the
electronic health record.
April 11, 2018
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
https://psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
Increased workload associated with electronic health record (EHR) …
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/854389/psn-pdf
October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus
Bundle on Sepsis in Obstetric Care.
October 11, 2023
Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on
Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304.
https://…
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psnet.ahrq.gov/node/838641/psn-pdf
October 19, 2022 - Optimizing Pediatric Patient Safety in the Emergency Care
Setting.
October 19, 2022
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care
Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
https://psnet.ahrq.gov/issue/optimizing-pediatric-patient-s…
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psnet.ahrq.gov/node/44935/psn-pdf
April 15, 2016 - Pharmacy-led medication reconciliation programmes at
hospital transitions: a systematic review and meta-
analysis.
April 15, 2016
Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital
transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):12…
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psnet.ahrq.gov/node/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/60813/psn-pdf
January 01, 2021 - Medication-related interventions delivered both in
hospital and following discharge: a systematic review and
meta-analysis.
August 19, 2020
Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and
following discharge: a systematic review and meta-analysis. BMJ Qua…
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psnet.ahrq.gov/node/838080/psn-pdf
September 14, 2022 - Effect on diagnostic accuracy of cognitive reasoning
tools for the workplace setting: systematic review and
meta-analysis.
September 14, 2022
Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the
workplace setting: systematic review and meta-analysis. BMJ Qual S…