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psnet.ahrq.gov/node/837798/psn-pdf
August 10, 2022 - An evolution of reporting: identifying the missing link.
August 10, 2022
Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics
(Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761.
https://psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link…
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psnet.ahrq.gov/node/38503/psn-pdf
June 16, 2009 - Antimicrobial prescription errors in hospitalized children:
role of antimicrobial stewardship program in detection
and intervention.
June 16, 2009
Di Pentima C, Chan S, Eppes SC, et al. Antimicrobial prescription errors in hospitalized children: role of
antimicrobial stewardship program in detection and interventi…
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psnet.ahrq.gov/node/44091/psn-pdf
January 04, 2019 - Isolation precautions for visitors.
January 4, 2019
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp
Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
https://psnet.ahrq.gov/issue/isolation-precautions-visitors
This expert guidance provides recommendations …
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psnet.ahrq.gov/node/44241/psn-pdf
November 09, 2015 - The overlooked danger of delirium in hospitals.
November 9, 2015
Boodman SG. The Atlantic. June 7, 2015.
https://psnet.ahrq.gov/issue/overlooked-danger-delirium-hospitals
Delirium is a common unintended consequence of hospitalization, most often following a surgical
procedure. This magazine article discusses chara…
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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/43036/psn-pdf
March 27, 2014 - Redesigning hospital alarms for patient safety: alarmed
and potentially dangerous.
March 27, 2014
Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially
dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710.
https://psnet.ahrq.gov/issue/redesigning-hospital-alarms…
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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/839830/psn-pdf
November 09, 2022 - Walgreens will stop judging its pharmacy staffers by how
fast they work.
November 9, 2022
Kaplan A. NBC News. October 27, 2022.
https://psnet.ahrq.gov/issue/walgreens-will-stop-judging-its-pharmacy-staffers-how-fast-they-work
Suboptimal working conditions are a known contributor to errors in retail pharmacie…
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psnet.ahrq.gov/node/43183/psn-pdf
May 14, 2014 - Physician: 'I almost killed a patient' because of an
advance directive.
May 14, 2014
Betbeze P. HealthLeaders Media. May 2, 2014.
https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive
Reporting on how misinterpretation of advance directives and living wills can detract from patie…
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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/50577/psn-pdf
October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers
Report.
October 23, 2019
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
Ambulatory surgery centers (ASC) play an increasing role in com…
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psnet.ahrq.gov/node/42902/psn-pdf
January 29, 2014 - Improving Patient Safety Through Teamwork and Team
Training.
January 29, 2014
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
https://psnet.ahrq.gov/issue/improving-patient-safety-through-teamwork-and-team-training
Health care has been recently been directed toward focusing o…
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psnet.ahrq.gov/node/73101/psn-pdf
April 07, 2021 - Do No Harm: Are We Preventing Medication Errors in
Children with Medical Complexity?
March 31, 2021
Children's Healthcare Canada. April 7, 2021.
https://psnet.ahrq.gov/issue/do-no-harm-are-we-preventing-medication-errors-children-medical-complexity
Children are particularly vulnerable to medication errors. This se…
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psnet.ahrq.gov/node/41625/psn-pdf
December 02, 2014 - Effects of CPOE on provider cognitive workload: a
randomized crossover trial.
December 2, 2014
Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial.
Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408.
https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…
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psnet.ahrq.gov/node/47390/psn-pdf
September 19, 2018 - Antimicrobial Stewardship.
September 19, 2018
Cunha CB, ed. Med Clin North Am. 2018;102(5):797-976.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship
Antimicrobial stewardship programs are a key strategy to reduce overprescribing of antibiotics in hospitals.
This special issue explores approaches to engage a …
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psnet.ahrq.gov/node/47696/psn-pdf
February 22, 2019 - Operating room fires.
February 22, 2019
Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501.
doi:10.1097/ALN.0000000000002598.
https://psnet.ahrq.gov/issue/operating-room-fires
Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
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psnet.ahrq.gov/node/35387/psn-pdf
September 10, 2009 - A human factors engineering conceptual framework of
nursing workload and patient safety in intensive care
units.
September 10, 2009
Carayon P, Gurses AP. A human factors engineering conceptual framework of nursing workload and
patient safety in intensive care units. Intensive Crit Care Nurs. 2005;21(5):284-301.
h…
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psnet.ahrq.gov/node/48179/psn-pdf
August 21, 2019 - Is WHO's surgical safety checklist being hyped?
August 21, 2019
Urbach DR, Dimick JB, Haynes AB, et al. Is WHO's surgical safety checklist being hyped? BMJ.
2019;366:l4700. doi:10.1136/bmj.l4700.
https://psnet.ahrq.gov/issue/whos-surgical-safety-checklist-being-hyped
Checklists are a popular yet controversial stra…
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psnet.ahrq.gov/node/41156/psn-pdf
March 02, 2012 - The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction.
March 2, 2012
Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…
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psnet.ahrq.gov/node/38705/psn-pdf
June 17, 2009 - Ambulance stretcher adverse events.
June 17, 2009
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care.
2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
https://psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
This study analyzed more than 670 reported adverse events …