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psnet.ahrq.gov/node/46253/psn-pdf
August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to
improve antimicrobial use.
August 28, 2017
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve
Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
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psnet.ahrq.gov/node/43786/psn-pdf
December 17, 2014 - Aviation tools to improve patient safety.
December 17, 2014
Ross J. Aviation tools to improve patient safety. J Perianesth Nurs. 2014;29(6):508-10.
doi:10.1016/j.jopan.2014.09.004.
https://psnet.ahrq.gov/issue/aviation-tools-improve-patient-safety
The aviation industry offers insights and tools applicable to error…
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psnet.ahrq.gov/node/47028/psn-pdf
May 02, 2018 - Medication errors 2018: the year in review.
May 2, 2018
Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018.
https://psnet.ahrq.gov/issue/medication-errors-2018-year-review
Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…
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psnet.ahrq.gov/node/60263/psn-pdf
April 22, 2020 - Rationing protective gear means checking on coronavirus
patients less often. This can be deadly.
April 22, 2020
Kaplan J, Presser L, Miller M. ProPublica. April 10, 2020.
https://psnet.ahrq.gov/issue/rationing-protective-gear-means-checking-coronavirus-patients-less-often-can-
be-deadly
Increased complexity and p…
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psnet.ahrq.gov/node/836759/psn-pdf
April 06, 2022 - Diversion is a Threat to Patient Safety: Adopting Best
Practices.
March 16, 2022
Institute for Safe Medication Practices. April 6, 2022.
https://psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
Drug diversion can result in patient harm due to reduced medication availability, impai…
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psnet.ahrq.gov/node/42468/psn-pdf
August 07, 2013 - A comprehensive quality assurance program for
personnel and procedures in radiation oncology: value of
voluntary error reporting and checklists.
August 7, 2013
Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and
procedures in radiation oncology: value of volunt…
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psnet.ahrq.gov/node/37262/psn-pdf
December 19, 2011 - Academic detailing to improve laboratory testing among
outpatient medication users.
December 19, 2011
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient
medication users. Med Care. 2007;45(10):966-72.
https://psnet.ahrq.gov/issue/academic-detailing-improve-laborat…
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psnet.ahrq.gov/node/34721/psn-pdf
November 19, 2015 - Preventing medical injury.
November 19, 2015
Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull.
1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x.
https://psnet.ahrq.gov/issue/preventing-medical-injury
Reviewing cases of medical error in the Harvard Medical Practice Study…
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psnet.ahrq.gov/node/72687/psn-pdf
January 27, 2021 - Learning from errors with the new COVID-19 vaccines.
January 27, 2021
ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
https://psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
Learning from error rests on transparency efforts buttressed by frontline reports. This a…
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psnet.ahrq.gov/node/42643/psn-pdf
October 09, 2013 - FDA requiring color changes to Duragesic (fentanyl) pain
patches to aid safety?emphasizing that accidental
exposure to used patches can cause death.
October 9, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013.
https://psnet.ahrq.gov/issue/fda-requiring-color-change…
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psnet.ahrq.gov/node/34697/psn-pdf
December 08, 2010 - Sentinel events. In memory of Ben—a case study.
December 8, 2010
Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5.
https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
Written from the perspective of a risk manager, the author tells the story of a medication a…
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psnet.ahrq.gov/node/46945/psn-pdf
August 29, 2018 - Patient safety initiatives in obstetrics: a rapid review.
August 29, 2018
Antony J, Zarin W, Pham B', et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open.
2018;8(7):e020170. doi:10.1136/bmjopen-2017-020170.
https://psnet.ahrq.gov/issue/patient-safety-initiatives-obstetrics-rapid-review
Variou…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/862151/psn-pdf
February 07, 2024 - Taking up the challenge to improve name and role
recognition in the operating room.
February 7, 2024
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the
operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.0000000000001177.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…
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psnet.ahrq.gov/node/47855/psn-pdf
June 19, 2019 - Medication Overload: America's Other Drug Problem.
June 19, 2019
Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
Overprescribing is a common problem that contributes to patient harm. This report examines financial,
clinical, an…
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psnet.ahrq.gov/node/34981/psn-pdf
July 14, 2010 - Child-specific risk factors and patient safety.
July 14, 2010
Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22.
https://psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
To discover factors that may contribute to a child’s risk for error during hospitalization, this study iden…
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psnet.ahrq.gov/node/47089/psn-pdf
May 09, 2018 - Leadership Survey: Immunization Against Burnout:
Insights Report.
May 9, 2018
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
https://psnet.ahrq.gov/issue/leadership-survey-immunization-against-burnout-insights-report
Clinician burnout presents challenges to organizational and p…
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psnet.ahrq.gov/node/851461/psn-pdf
July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating
them.
July 19, 2023
Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395.
doi:10.1097/pts.0000000000001140.
https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them
…
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psnet.ahrq.gov/node/44224/psn-pdf
June 10, 2015 - To be sued less, doctors should consider talking to
patients more.
June 10, 2015
Carroll AE.
https://psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
Reporting on trends associated with medical malpractice, how the same physicians tend to get sued, and
reasons patients file claims, …