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psnet.ahrq.gov/node/40406/psn-pdf
February 13, 2018 - Critical conversations: a call for a nonprocedural "time
out."
February 13, 2018
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp
Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
https://psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
This…
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psnet.ahrq.gov/node/43491/psn-pdf
January 01, 2015 - The systems approach to medicine: controversy and
misconceptions.
December 9, 2014
Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ
Qual Saf. 2015;24(1):7-9. doi:10.1136/bmjqs-2014-003106.
https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconcept…
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www.ahrq.gov/topics/medicaid.html
Topic: Medicaid
Medicaid is state-based government health insurance that helps many low-income people in the United States to pay their medical bills.
Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Me…
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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/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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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/73431/psn-pdf
June 23, 2021 - Drive to Deprescribe.
June 23, 2021
The Society for Post-Acute and Long-Term Care Medicine.
https://psnet.ahrq.gov/issue/drive-deprescribe
Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care
organizations, physicians, and pharmacists to take part in a learning net…
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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/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/41972/psn-pdf
January 23, 2013 - Impact of a pharmacotherapy alerting system on
medication errors.
January 23, 2013
Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors.
American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.
https://psnet.ahrq.gov/issue/impact-pharmacothe…
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psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
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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/50727/psn-pdf
December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been
a factor?
December 11, 2019
Glicksman E. Washington Post. November 17, 2019.
https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
Unconscious assumptions and biases are known contributors to poor decision-making. This news st…
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psnet.ahrq.gov/node/37653/psn-pdf
May 14, 2008 - Getting boards on board: engaging governing boards in
quality and safety.
May 14, 2008
Conway JB. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual
Saf. 2008;34(4):214-220.
https://psnet.ahrq.gov/issue/getting-boards-board-engaging-governing-boards-quality-and-safety
This a…
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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/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/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/37704/psn-pdf
April 23, 2008 - Decreasing paediatric prescribing errors in a district
general hospital.
April 23, 2008
Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital.
Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212.
https://psnet.ahrq.gov/issue/decreasing-paediatric-…
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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/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…