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psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…
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psnet.ahrq.gov/node/50387/psn-pdf
September 25, 2019 - Special Issue on Prescription Drug Misuse.
September 25, 2019
Rickles NM, Fleming ML, Björnsdottir I, eds. Res Social Adm Pharm. 2019;15:907-1056.
https://psnet.ahrq.gov/issue/special-issue-prescription-drug-misuse
This special issue reviews research initiatives exploring persistent challenges associated with the
…
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psnet.ahrq.gov/node/39166/psn-pdf
December 09, 2009 - Effectiveness of a pharmacist–nurse intervention on
resolving medication discrepancies for patients
transitioning from hospital to home health care.
December 9, 2009
Setter SM, Corbett CF, Neumiller JJ, et al. Effectiveness of a pharmacist-nurse intervention on resolving
medication discrepancies for patients trans…
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psnet.ahrq.gov/node/48142/psn-pdf
August 21, 2019 - Six ways to lower errors—and unnecessary surgeries—in
radiology exams.
August 21, 2019
Panner M. Forbes. August 12, 2019.
https://psnet.ahrq.gov/issue/six-ways-lower-errors-and-unnecessary-surgeries-radiology-exams
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and syste…
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psnet.ahrq.gov/node/47904/psn-pdf
April 24, 2019 - Air pressure: human factors are the key to a safer flight
environment.
April 24, 2019
Erich J. EMS World. April 2019;48:26-31.
https://psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment
Air transport service combines risks associated with both aviation and prehospital trauma care. Thi…
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psnet.ahrq.gov/node/46341/psn-pdf
August 16, 2017 - In treating sepsis, questions about timing and mandates.
August 16, 2017
Abbasi J. In Treating Sepsis, Questions About Timing and Mandates. JAMA. 2017;318(6):506-508.
doi:10.1001/jama.2017.7997.
https://psnet.ahrq.gov/issue/treating-sepsis-questions-about-timing-and-mandates
Delayed treatment of sepsis can result …
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psnet.ahrq.gov/node/45549/psn-pdf
October 12, 2016 - Preventing diagnostic errors in primary care.
October 12, 2016
Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32.
https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
The Improving Diagnosis in Health Care report advocated for enhancing patient en…
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psnet.ahrq.gov/node/38226/psn-pdf
February 18, 2011 - Critical events in the lives of interns.
February 18, 2011
Ackerman A, Graham M, Schmidt H, et al. Critical events in the lives of interns. J Gen Intern Med.
2009;24(1):27-32. doi:10.1007/s11606-008-0769-8.
https://psnet.ahrq.gov/issue/critical-events-lives-interns
Resident physicians remain at high risk for burno…
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psnet.ahrq.gov/node/863223/psn-pdf
February 28, 2024 - Prioritizing Patient Safety Through Quality Measurement.
February 28, 2024
Centers for Medicare & Medicaid Services, March 6 and 21, 2024.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement
Quality measurement intersects with patient safety and care improvement efforts to…
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psnet.ahrq.gov/node/842431/psn-pdf
January 11, 2023 - Confronting racism in pediatric care.
January 11, 2023
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685.
doi:10.1377/hlthaff.2022.01157.
https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care
Racism is a patient safety issue that is gaining the increased attention ne…
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psnet.ahrq.gov/node/837979/psn-pdf
August 31, 2022 - Maternal Health Research Centers of Excellence (U54
Clinical Trial Optional).
August 31, 2022
National Institutes of Health. August 11, 2022. RFA-HD-23-035.
https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
Maternity care is increasingly being recognized as …
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psnet.ahrq.gov/node/837861/psn-pdf
August 17, 2022 - Skin cancer is a risk no matter the skin tone. But it may
be overlooked in people with dark skin.
August 17, 2022
West S. Kaiser Health News. August 5, 2022.
https://psnet.ahrq.gov/issue/skin-cancer-risk-no-matter-skin-tone-it-may-be-overlooked-people-dark-skin
The article highlights skin cancer identification pro…
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psnet.ahrq.gov/node/50781/psn-pdf
January 08, 2020 - Harnessing the power of medical malpractice data to
improve patient care.
January 8, 2020
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care.
J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
https://psnet.ahrq.gov/issue/harnessing-power-medic…
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psnet.ahrq.gov/node/72598/psn-pdf
January 01, 2021 - Hospital medication errors: a cross sectional study.
December 23, 2020
ISAACS AN, Ch'ng K, DELHIWALE N, et al. Hospital medication errors: a cross-sectional study. Int J Qual
Health Care. 2021;33(1):mzaa136. doi:10.1093/intqhc/mzaa136.
https://psnet.ahrq.gov/issue/hospital-medication-errors-cross-sectional-study
R…
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psnet.ahrq.gov/node/47386/psn-pdf
September 19, 2018 - Active-shooter response at a health care facility.
September 19, 2018
Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med.
2018;379(6):583-586. doi:10.1056/NEJMms1800582.
https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility
Physical and verbal…
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psnet.ahrq.gov/node/38420/psn-pdf
February 18, 2009 - Effect of short-term pretrial practice on surgical
proficiency in simulated environments: a randomized trial
of the "preoperative warm-up" effect.
February 18, 2009
Kahol K, Satava RM, Ferrara JJ, et al. Effect of Short-Term Pretrial Practice on Surgical Proficiency in
Simulated Environments: A Randomized Trial of…
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psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
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psnet.ahrq.gov/node/43270/psn-pdf
June 18, 2014 - Group urges going metric to head off dosing mistakes.
June 18, 2014
Budnitz DS, Lovegrove MC, Rose KO. Adherence to Label and Device Recommendations for Over-the-
Counter Pediatric Liquid Medications. PEDIATRICS. 2014;133(2). doi:10.1542/peds.2013-2362.
https://psnet.ahrq.gov/issue/group-urges-going-metric-head-dos…
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psnet.ahrq.gov/node/34637/psn-pdf
March 02, 2011 - Risk management: extreme honesty may be the best
policy.
March 2, 2011
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med.
1999;131(12):963-967.
https://psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy
This article reviews a humanistic risk management…
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psnet.ahrq.gov/node/44846/psn-pdf
August 31, 2016 - Making health care safer: protect patients from antibiotic
resistance.
August 31, 2016
CDC; Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance
Health care–associated infections (HAI) are a worldwide patient safety problem. This a…