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psnet.ahrq.gov/node/41955/psn-pdf
January 09, 2013 - Making Medical Devices Safer at Home.
January 9, 2013
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
https://psnet.ahrq.gov/issue/making-medical-devices-safer-home
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty
understand…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-d.pdf
June 02, 2025 - Appendix D. Poster on Indications for Urinary Catheters
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix D. Poster on Indications for Urinary Catheters
In lower right, use Adobe Acrobat Pro to insert contact information for your institution.
Does your patient
really nee…
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psnet.ahrq.gov/node/42364/psn-pdf
September 18, 2013 - The pursuit of better diagnostic performance: a human
factors perspective.
September 18, 2013
Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ
Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827.
https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…
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psnet.ahrq.gov/node/36431/psn-pdf
March 28, 2011 - Using the internet to deliver education on drug safety.
March 28, 2011
Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health
Care. 2006;15(5):329-33.
https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
The project team implemented a web-…
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psnet.ahrq.gov/node/43318/psn-pdf
July 02, 2014 - Sign up to Safety.
July 2, 2014
National Health Service.
https://psnet.ahrq.gov/issue/sign-safety
Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to
Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service
facilities.…
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psnet.ahrq.gov/node/40696/psn-pdf
December 01, 2011 - Rapid response systems: a prospective study of
response times.
December 1, 2011
Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J
Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013.
https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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psnet.ahrq.gov/node/40568/psn-pdf
June 29, 2011 - Tubing misconnections: normalization of deviance.
June 29, 2011
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract.
2011;26(3):286-293. doi:10.1177/0884533611406134.
https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
Analyzing published ca…
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psnet.ahrq.gov/node/40903/psn-pdf
March 08, 2015 - Does your patient really understand?
March 8, 2015
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
https://psnet.ahrq.gov/issue/does-your-patient-really-understand
This article discusses health literacy and describes an initiative to reduce gaps in understanding …
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psnet.ahrq.gov/node/44436/psn-pdf
October 30, 2017 - Overreaction.
October 30, 2017
Shell ER. Overreaction. Scientific American. 2015;313(5):28-9.
https://psnet.ahrq.gov/issue/overreaction
Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential
consequences, this magazine article describes a diagnostic tool to dete…
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psnet.ahrq.gov/node/39766/psn-pdf
August 18, 2010 - Paediatric dosing errors before and after electronic
prescribing.
August 18, 2010
Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf
Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068.
https://psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-elec…
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psnet.ahrq.gov/node/39465/psn-pdf
May 08, 2018 - Latest heparin fatality speaks loudly—what have you
done to stop the bleeding?
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
Detailing a recent lethal overdose of heparin, this …
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psnet.ahrq.gov/node/42344/psn-pdf
September 24, 2016 - Strategies for preventing distractions and interruptions in
the OR.
September 24, 2016
Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707.
doi:10.1016/j.aorn.2013.01.018.
https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or
Dist…
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psnet.ahrq.gov/node/37749/psn-pdf
July 16, 2018 - Practice advisory for the prevention and management of
operating room fires.
July 16, 2018
Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management
of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2.
doi:10.1097/01.anes.0000299343.87119.a9.
htt…
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psnet.ahrq.gov/node/36039/psn-pdf
March 02, 2011 - The effects of on-duty napping on intern sleep time and
fatigue.
March 2, 2011
Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann
Intern Med. 2006;144(11):792-8.
https://psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue
The investigators …
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psnet.ahrq.gov/node/40668/psn-pdf
March 04, 2015 - Body CT: technical advances for improving safety.
March 4, 2015
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J
Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
This article explores risk…
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/contextualizing
January 01, 2023 - Contextualizing care: An essential and measurable clinical competency.
Citation
Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022 Mar;105(3):594-598. doi: 10.1016/j.pec.2021.06.016. Epub 2021 Jun 15. PMID: 34158194.
Link
https://pubmed.n…
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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/46466/psn-pdf
July 11, 2018 - Distinct newborn identification requirement.
July 11, 2018
R3 Report. June 25, 2018;7:1-2.
https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement
Neonatal patients are at risk for misidentification due to communication challenges and lack of
distinguishable features. This report highlights new Jo…
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psnet.ahrq.gov/node/42830/psn-pdf
December 18, 2013 - How to Identify and Address Unsafe Conditions
Associated With Health IT.
December 18, 2013
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National
Coordinator for Health Information Technology; November 15, 2013.
https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…