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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/849133/psn-pdf
May 17, 2023 - The association between patient safety culture and
adverse events - a scoping review.
May 17, 2023
Vikan M, Haugen AS, Bjørnnes AK, et al. The association between patient safety culture and adverse
events – a scoping review. BMC Health Serv Res. 2023;23(1):300. doi:10.1186/s12913-023-09332-8.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46931/psn-pdf
January 15, 2019 - Strategies for optimizing OR drug safety.
January 15, 2019
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
https://psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety
Perioperative adverse drug events are common and understudied. Reporting on the complexity of
medication administration durin…
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psnet.ahrq.gov/node/44378/psn-pdf
August 05, 2015 - Advancing medication safety: establishing a National
Action Plan for Adverse Drug Event Prevention.
August 5, 2015
Harris Y, Hu DJ, Lee C, et al. Advancing Medication Safety: Establishing a National Action Plan for
Adverse Drug Event Prevention. Jt Comm J Qual Patient Saf. 2015;41(8):351-60.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837040/psn-pdf
May 04, 2022 - Use duodenoscopes with innovative designs to enhance
safety: FDA Safety Communication.
May 4, 2022
Silver Spring, MD: US Food and Drug Administration; April 5, 2022.
https://psnet.ahrq.gov/issue/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-
communication
The challenge of medical device steriliza…
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psnet.ahrq.gov/node/866250/psn-pdf
July 10, 2024 - Attention among health care professionals : a scoping
review.
July 10, 2024
Kissler MJ, Porter S, Knees M, et al. Attention among health care professionals : a scoping review. Ann
Intern Med. 2024;177(7):941-952. doi:10.7326/m23-3229.
https://psnet.ahrq.gov/issue/attention-among-health-care-professionals-scoping-r…
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psnet.ahrq.gov/node/45440/psn-pdf
November 09, 2016 - Safety lessons from the NIH Clinical Center.
November 9, 2016
Gandhi TK. Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707.
https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center
System failures can remain undetected over time in large organizations. This perspective describ…
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psnet.ahrq.gov/node/45782/psn-pdf
January 18, 2017 - Standardization of inpatient handoff communication.
January 18, 2017
Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681.
doi:10.1542/peds.2016-2681.
https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication
Handoffs at shift changes are vulnerable to…
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psnet.ahrq.gov/node/41546/psn-pdf
December 29, 2014 - Using a logic model to design and evaluate quality and
patient safety improvement programs.
December 29, 2014
Goeschel CA, Weiss WM, Pronovost P. Using a logic model to design and evaluate quality and patient
safety improvement programs. Int J Qual Health Care. 2012;24(4):330-7. doi:10.1093/intqhc/mzs029.
https://…
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psnet.ahrq.gov/node/47646/psn-pdf
February 06, 2019 - Systematic review of computerized prescriber order entry
and clinical decision support.
February 6, 2019
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized
prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921.
doi:10.214…
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psnet.ahrq.gov/node/849336/psn-pdf
May 24, 2023 - AI may be on its way to your doctor’s office, but it’s not
ready to see patients.
May 24, 2023
Tahir D. KFF Health News. May 12, 2023.
https://psnet.ahrq.gov/issue/ai-may-be-its-way-your-doctors-office-its-not-ready-see-patients
Real-time use of artificial intelligence (AI) in health care settings continues to cau…
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psnet.ahrq.gov/node/47881/psn-pdf
July 10, 2019 - Cognitive Errors and Diagnostic Mistakes: A Case-Based
Guide to Critical Thinking in Medicine.
July 10, 2019
Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.
https://psnet.ahrq.gov/issue/cognitive-errors-and-diagnostic-mistakes-case-based-guide-critical-thinking-
medicine
Cogni…
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psnet.ahrq.gov/node/853058/psn-pdf
August 30, 2023 - Diagnostic reliability in teledermatology: a systematic
review and a meta-analysis.
August 30, 2023
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review
and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/837630/psn-pdf
July 06, 2022 - Mandating limits on workload, duty, and speed in
radiology.
July 6, 2022
Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology.
Radiology. 2022:212631. doi:10.1148/radiol.212631.
https://psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology
To reduce m…
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psnet.ahrq.gov/node/40404/psn-pdf
February 10, 2015 - The quality 'journey' at Ascension Health: how we've
prevented at least 1,500 avoidable deaths a year—and aim
to do even better.
February 10, 2015
Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at
least 1,500 avoidable deaths a year--and aim to do even better.…
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psnet.ahrq.gov/node/45188/psn-pdf
June 01, 2016 - Reporting and second-order problem solving can turn
short-term fixes into long-term remedies.
June 1, 2016
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-
term-remedies
Workarounds are pr…
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psnet.ahrq.gov/node/45530/psn-pdf
October 19, 2016 - As a critical behavior to improve quality and patient
safety in health care: speaking up!
October 19, 2016
Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety
in Health. 2016;2(1). doi:10.1186/s40886-016-0021-x.
https://psnet.ahrq.gov/issue/critical-behavio…
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psnet.ahrq.gov/node/73476/psn-pdf
July 07, 2021 - The role of apology laws in medical malpractice.
July 7, 2021
Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414.
https://psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians
frequently ci…
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psnet.ahrq.gov/node/39731/psn-pdf
August 04, 2010 - Comparing errors in ED computer-assisted vs
conventional pediatric drug dosing and administration.
August 4, 2010
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug
dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009.
https://ps…
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psnet.ahrq.gov/node/40281/psn-pdf
August 25, 2011 - Effects of a clinical pharmacist service on health-related
quality of life and prescribing of drugs: a randomised
controlled trial.
August 25, 2011
Bladh L, Ottosson E, Karlsson J, et al. Effects of a clinical pharmacist service on health-related quality of
life and prescribing of drugs: a randomised controlled tr…