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psnet.ahrq.gov/node/42160/psn-pdf
April 03, 2013 - The perianesthesia nurse's role in the prevention of
opioid-related sentinel events.
April 3, 2013
Pasero C. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. J Perianesth
Nurs. 2013;28(1):31-7. doi:10.1016/j.jopan.2012.11.001.
https://psnet.ahrq.gov/issue/perianesthesia-nurses-r…
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psnet.ahrq.gov/node/40502/psn-pdf
January 01, 2020 - New 2012 National Patient Safety Goal - catheter-
associated urinary tract infection (CAUTI).
June 1, 2011
Joint Commission.
https://psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract-
infection-cauti
This announcement reveals the new National Patient Safety Goal for 2012…
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psnet.ahrq.gov/node/46408/psn-pdf
November 29, 2017 - Eliminating vincristine administration events.
November 29, 2017
Quick Safety. October 16, 2017;(37):1-3.
https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
Vincristine administration errors can have serious consequences. This newsletter article outlines steps to
reduce risks associated wit…
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psnet.ahrq.gov/node/73872/psn-pdf
September 22, 2021 - Parenteral nutrition safety.
September 22, 2021
Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.
https://psnet.ahrq.gov/issue/parenteral-nutrition-safety
Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm.
This article discusses …
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psnet.ahrq.gov/node/45638/psn-pdf
January 01, 2019 - Measures to improve diagnostic safety in clinical practice.
November 2, 2016
Singh H, Graber ML, Hofer TP. Measures to Improve Diagnostic Safety in Clinical Practice. J Patient Saf.
2019;15(4):311-316. doi:10.1097/PTS.0000000000000338.
https://psnet.ahrq.gov/issue/measures-improve-diagnostic-safety-clinical-practic…
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psnet.ahrq.gov/node/37359/psn-pdf
January 02, 2017 - Case study: preventing surgical complications at
Baystate Medical Center.
January 2, 2017
Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical
Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553-
7250(07)33076-6.
http…
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psnet.ahrq.gov/node/40865/psn-pdf
September 12, 2016 - A review of current and emerging approaches to address
failure-to-rescue.
September 12, 2016
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-
rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
https://psnet.ahrq.gov/issue/review-current-…
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psnet.ahrq.gov/node/42197/psn-pdf
September 24, 2016 - Interruptions during nurses' work: a state-of-the-science
review.
September 24, 2016
Hopkinson SG, Jennings BM. Interruptions during nurses' work: A state-of-the-science review. Res Nurs
Health. 2013;36(1):38-53. doi:10.1002/nur.21515.
https://psnet.ahrq.gov/issue/interruptions-during-nurses-work-state-science-rev…
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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/36976/psn-pdf
June 15, 2011 - Evaluation of an intervention aimed at improving
voluntary incident reporting in hospitals.
June 15, 2011
Evans S, Smith B, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident
reporting in hospitals. Qual Saf Health Care. 2007;16(3):169-75.
https://psnet.ahrq.gov/issue/evaluation…
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psnet.ahrq.gov/node/836788/psn-pdf
March 23, 2022 - A widow’s mission to change NC dental sedation rules.
March 23, 2022
Blythe A. NC Health News. March 10, 2022
https://psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules
Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication
incident and the lack of …
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psnet.ahrq.gov/node/41053/psn-pdf
December 30, 2014 - Time to accelerate integration of human factors and
ergonomics in patient safety.
December 30, 2014
Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in
patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421.
https://psnet.ahrq.gov/issue/time-acc…
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psnet.ahrq.gov/node/39807/psn-pdf
December 29, 2014 - Perspectives in quality: designing the WHO Surgical
Safety Checklist.
December 29, 2014
Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety
Checklist. Int J Qual Health Care. 2010;22(5):365-70. doi:10.1093/intqhc/mzq039.
https://psnet.ahrq.gov/issue/perspectives-qual…
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psnet.ahrq.gov/node/45237/psn-pdf
June 15, 2016 - Medication reconciliation in oncological patients: a
randomized clinical trial.
June 15, 2016
Vega TG-C, Sierra-Sánchez JF, Martínez-Bautista MJ, et al. Medication Reconciliation in Oncological
Patients: A Randomized Clinical Trial. J Manag Care Spec Pharm. 2016;22(6):734-40.
doi:10.18553/jmcp.2016.15248.
https:/…
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psnet.ahrq.gov/node/46494/psn-pdf
January 24, 2018 - Complications.
January 24, 2018
Anaesthesia. 2018;73(suppl 1):3-101.
https://psnet.ahrq.gov/issue/complications
Study of complications can provide insights into presurgical patient counseling, risk assessment, and
medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…
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psnet.ahrq.gov/node/36387/psn-pdf
July 14, 2010 - Effectiveness of a community collaborative for
eliminating the use of high-risk abbreviations written by
physicians.
July 14, 2010
Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk
Abbreviations Written by Physicians. J Patient Saf. 2008;2(3). doi:10.1097/0…
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psnet.ahrq.gov/node/853629/psn-pdf
September 20, 2023 - Global Knowledge Sharing Platform for Patient Safety.
September 20, 2023
World Health Organization.
https://psnet.ahrq.gov/issue/global-knowledge-sharing-platform-patient-safety
The sharing of best practices is a key component of enabling successful strategy implementation in support
of patient safety plans and go…
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psnet.ahrq.gov/node/50878/psn-pdf
February 05, 2020 - The role of racism as a core patient safety issue.
February 5, 2020
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-
61.
https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
A variety of biases can reduce the effectiveness and safety of care.…
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psnet.ahrq.gov/node/39626/psn-pdf
June 23, 2010 - The Medication Manager: results of a medication at the
bedside pilot in a pediatric teaching institution.
June 23, 2010
Wagner D, Pasko D, Glenn D, et al. The Medication Manager. J Patient Saf. 2010;6(2).
doi:10.1097/pts.0b013e3181cb43b4.
https://psnet.ahrq.gov/issue/medication-manager-results-medication-bedside-p…
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psnet.ahrq.gov/node/46596/psn-pdf
November 01, 2017 - Infection prevention and control in pediatric ambulatory
settings.
November 1, 2017
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
Patient safety in the ambulatory environme…