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psnet.ahrq.gov/node/73502/psn-pdf
July 14, 2021 - Toolkit to Improve Antibiotic Use in Long-Term Care.
July 14, 2021
Rockville, MD: Agency for Healthcare Research and Quality; June 2021.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-long-term-care
The use of antibiotics should be monitored to reduce the potential for infection in care facilities. Thi…
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psnet.ahrq.gov/node/45747/psn-pdf
December 21, 2016 - Implementing No Interruption Zones in the perioperative
environment.
December 21, 2016
Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536-
540. doi:10.1016/j.aorn.2016.09.018.
https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…
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psnet.ahrq.gov/node/60663/psn-pdf
January 01, 2021 - Apology laws and malpractice liability: what have we
learned?
July 8, 2020
Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual
Saf. 2021;30(1):64-67. doi:10.1136/bmjqs-2020-010955.
https://psnet.ahrq.gov/issue/apology-laws-and-malpractice-liability-what-have-we-l…
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psnet.ahrq.gov/node/866638/psn-pdf
September 04, 2024 - The problem with 'never events'.
September 4, 2024
Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616.
doi:10.1136/bmjqs-2023-016981.
https://psnet.ahrq.gov/issue/problem-never-events
Never events are serious, but preventable, adverse events that result in serious pati…
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psnet.ahrq.gov/node/43948/psn-pdf
May 20, 2015 - Human factors engineering: its place and potential in OR
safety.
May 20, 2015
Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3.
doi:10.1016/j.aorn.2015.02.013.
https://psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
Human fa…
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psnet.ahrq.gov/node/836754/psn-pdf
March 16, 2022 - State of science: evolving perspectives on ‘human error’.
March 16, 2022
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’.
Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…
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psnet.ahrq.gov/node/43415/psn-pdf
September 10, 2014 - Project BOOST implementation: lessons learned.
September 10, 2014
Williams M, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J.
2014;107(7):455-65. doi:10.14423/SMJ.0000000000000140.
https://psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned
This qualitative study o…
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psnet.ahrq.gov/node/35628/psn-pdf
June 23, 2010 - Medical professional liability insurance and its relation to
medical error and healthcare risk management for the
practicing physician.
June 23, 2010
Abbott RL, Weber P, Kelley B. Medical professional liability insurance and its relation to medical error and
healthcare risk management for the practicing physician.…
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psnet.ahrq.gov/node/43562/psn-pdf
September 24, 2014 - What's that sound? Managing alarm fatigue.
September 24, 2014
George TP, Martin V. What?s that sound? Managing alarm fatigue. Nursing Made Incredibly Easy!.
2014;12(5). doi:10.1097/01.nme.0000452689.19763.3f.
https://psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
Alarm fatigue has been described as a cont…
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psnet.ahrq.gov/node/41510/psn-pdf
July 11, 2012 - Dangerous connections: health care community tackles
tubing risks, small-bore connector standards.
July 11, 2012
Vockley M. Joint Commission: The Source. June 2012;10:15-17.
https://psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small-
bore-connector
This newsletter article …
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psnet.ahrq.gov/node/47765/psn-pdf
February 20, 2019 - Negative behaviours in health care: prevalence and
strategies.
February 20, 2019
Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J
Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660.
https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…
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psnet.ahrq.gov/node/38541/psn-pdf
May 21, 2009 - The relationship between inpatient cardiac surgery
mortality and nurse numbers and educational level:
analysis of administrative data.
May 21, 2009
Van den Heede K, Lesaffre E, Diya L, et al. The relationship between inpatient cardiac surgery mortality
and nurse numbers and educational level: analysis of administr…
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psnet.ahrq.gov/node/46469/psn-pdf
October 25, 2017 - RxAwareness.
October 25, 2017
Centers for Disease Control and Prevention; CDC.
https://psnet.ahrq.gov/issue/rxawareness
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to
raise awareness of the addictive nature of the medication. This national campaign enlists…
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psnet.ahrq.gov/node/46477/psn-pdf
January 08, 2018 - The iatrogenic potential of the physician's words.
January 8, 2018
Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017;318(24):2425-2426.
doi:10.1001/jama.2017.16216.
https://psnet.ahrq.gov/issue/iatrogenic-potential-physicians-words
Inadequate information sharing between physicians and patien…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/43734/psn-pdf
January 21, 2015 - Explicit and Standardized Prescription Medicine
Instructions.
January 21, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions
Standardization has been embraced as a strategy to improve health litera…
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psnet.ahrq.gov/node/47196/psn-pdf
October 17, 2018 - Adaptive expertise in medical decision making.
October 17, 2018
Croskerry P. Adaptive expertise in medical decision making. Med Teach. 2018;40(8):803-808.
doi:10.1080/0142159X.2018.1484898.
https://psnet.ahrq.gov/issue/adaptive-expertise-medical-decision-making
Clinical reasoning is a complex process that can be i…
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psnet.ahrq.gov/node/864386/psn-pdf
March 13, 2024 - Time for prefilled syringes - everywhere.
March 13, 2024
Whitaker DK, Lomas JP. Time for prefilled syringes – everywhere. Anaesthesia. 2024;79(2):119-122.
doi:10.1111/anae.16181.
https://psnet.ahrq.gov/issue/time-prefilled-syringes-everywhere
Simplifying complex processes is a strategy to engineer safety into heal…
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psnet.ahrq.gov/node/37555/psn-pdf
February 14, 2018 - ACOG Committee Opinion #730: fatigue and patient
safety.
February 14, 2018
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2018;131(2):e78-
e81.
https://psnet.ahrq.gov/issue/acog-committee-opinion-730-fatigue-and-patient-safety
This commentary discusses how sleep deprivation affects…
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psnet.ahrq.gov/node/764408/psn-pdf
March 02, 2022 - Ensuring critical instruments and devices are appropriate
for reuse.
March 2, 2022
Quick Safety. February 14, 2022;(64):1-3.
https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …