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psnet.ahrq.gov/node/61047/psn-pdf
October 21, 2020 - COVID-19: an emerging threat to antibiotic stewardship in
the emergency department.
October 21, 2020
Pulia M, Wolf I, Schulz L, et al. COVID-19: an emerging threat to antibiotic stewardship in the emergency
department. West J Emerg Med. 2020;21(5):1283-1286. doi:10.5811/westjem.2020.7.48848.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45826/psn-pdf
January 18, 2017 - Ensuring staff safety when treating potentially violent
patients.
January 18, 2017
Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA.
2016;316(24):2669-2670. doi:10.1001/jama.2016.18260.
https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…
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digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end/citation/shared
January 01, 2023 - A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: Design and usability study.
Citation
Reese TJ, Del Fiol G, Morgan K, Hurwitz JT, Kawamoto K, Gomez-Lumbreras A, Brown ML, Thiess H, Vazquez SR, Nelson SD, Boyce R, Malone D. A shared decisio…
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www.ahrq.gov/action-alliance/webinars/addressing-workforce-burnout.html
December 01, 2024 - National Action Alliance Webinar: Addressing Healthcare Workforce Burnout
Summary Burnout among healthcare staff is at a critical level, making the need for effective solutions more urgent than ever. This webinar held on November 12, part of a series on workforce safety and well-being, examined strategies for r…
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psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
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psnet.ahrq.gov/node/46020/psn-pdf
July 21, 2017 - Towards high-reliability organising in healthcare: a
strategy for building organisational capacity.
July 21, 2017
Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for
building organisational capacity. BMJ Qual Saf. 2017;26(8):663-670. doi:10.1136/bmjqs-2016-00624…
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psnet.ahrq.gov/node/40892/psn-pdf
February 06, 2012 - Four years' experience with a hospitalist-led medical
emergency team: an interrupted time series.
February 6, 2012
Rothberg MB, Belforti R, Fitzgerald J, et al. Four years' experience with a hospitalist-led medical
emergency team: an interrupted time series. J Hosp Med. 2012;7(2):98-103. doi:10.1002/jhm.953.
https…
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psnet.ahrq.gov/node/60992/psn-pdf
October 14, 2020 - Another medical malpractice crisis?: Try something
different.
October 14, 2020
Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different.
JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557.
https://psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-d…
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psnet.ahrq.gov/node/72852/psn-pdf
March 17, 2021 - Declaring uncertainty: using quality improvement
methods to change the conversation of diagnosis.
March 17, 2021
Ipsaro AJ, Patel SJ, Warner DC, et al. Declaring Uncertainty: Using Quality Improvement Methods to
Change the Conversation of Diagnosis. Hosp Pediatr. 2021;11(4):334-341. doi:10.1542/hpeds.2020-
000174.…
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psnet.ahrq.gov/node/44425/psn-pdf
February 24, 2016 - Dangerous doses.
February 24, 2016
Roe S, King K. Chicago Tribune. February 10–13, 2016.
https://psnet.ahrq.gov/issue/dangerous-doses
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age
and use of medications for chronic conditions. This series of news reports d…
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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/node/45383/psn-pdf
August 31, 2016 - Case report of a medication error: in the eye of the
beholder.
August 31, 2016
Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore).
2016;95(28):e4186. doi:10.1097/md.0000000000004186.
https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
Look-alike dr…
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psnet.ahrq.gov/node/43333/psn-pdf
January 15, 2017 - A multidisciplinary, multifaceted improvement initiative to
eliminate mislabelled laboratory specimens at a large
tertiary care hospital.
January 15, 2017
Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate
mislabelled laboratory specimens at a large tertiary…
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psnet.ahrq.gov/node/73966/psn-pdf
October 13, 2021 - Prescribing errors with low-molecular-weight heparins.
October 13, 2021
Slikkerveer M, van de Plas A, Driessen JHM, et al. Prescribing errors with low-molecular-weight heparins. J
Patient Saf. 2021;17(7):e587-e592. doi:10.1097/pts.0000000000000417.
https://psnet.ahrq.gov/issue/prescribing-errors-low-molecular-weigh…
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psnet.ahrq.gov/node/46205/psn-pdf
September 20, 2017 - The impact of checklists on inpatient safety outcomes: a
systematic review of randomized controlled trials.
September 20, 2017
Boyd J, Wu G, Stelfox HT. The Impact of Checklists on Inpatient Safety Outcomes: A Systematic Review of
Randomized Controlled Trials. J Hosp Med. 2017;12(8):675-682. doi:10.12788/jhm.2788.
…
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psnet.ahrq.gov/node/43997/psn-pdf
August 02, 2015 - Sentinel events, serious reportable events, and root
cause analysis.
August 2, 2015
Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis.
JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672.
https://psnet.ahrq.gov/issue/sentinel-events-serious-re…
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psnet.ahrq.gov/node/850349/psn-pdf
June 14, 2023 - Cognitive biases in internal medicine: a scoping review.
June 14, 2023
Loncharich MF, Robbins RC, Durning SJ, et al. Cognitive biases in internal medicine: a scoping review.
Diagnosis (Berl). 2023;10(3):205-214. doi:10.1515/dx-2022-0120.
https://psnet.ahrq.gov/issue/cognitive-biases-internal-medicine-scoping-review…
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psnet.ahrq.gov/node/46554/psn-pdf
October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin
pens at home.
October 25, 2017
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. October 12, 2017.
https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…
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psnet.ahrq.gov/node/44724/psn-pdf
November 25, 2015 - What's in your kit? A safety checkup may be in order.
November 25, 2015
Paparella S. What's In Your Kit? A Safety Checkup May Be In Order. Journal of emergency nursing: JEN :
official publication of the Emergency Department Nurses Association. 2015;41(6):513-5.
doi:10.1016/j.jen.2015.07.001.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47165/psn-pdf
June 13, 2018 - Changing how we think about healthcare improvement.
June 13, 2018
Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014.
doi:10.1136/bmj.k2014.
https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement
In learning organizations, leadership behavior creates a s…