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psnet.ahrq.gov/node/47737/psn-pdf
March 06, 2019 - Quality improvement and safety in pediatric emergency
medicine.
March 6, 2019
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine.
Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…
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psnet.ahrq.gov/node/851067/psn-pdf
June 28, 2023 - Assessing medication safety in settings not designated
solely for pediatric patients.
June 28, 2023
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
Pediatric patients are at increa…
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psnet.ahrq.gov/node/837503/psn-pdf
June 22, 2022 - A clinical reasoning curriculum for medical students: an
interim analysis.
June 22, 2022
Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim
analysis. Diagnosis (Berl). 2022;9(2):265-273. doi:10.1515/dx-2021-0112.
https://psnet.ahrq.gov/issue/clinical-reasoning-curri…
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psnet.ahrq.gov/node/850175/psn-pdf
June 07, 2023 - Explicitly addressing implicit bias on inpatient rounds:
student and faculty reflections.
June 7, 2023
Carter RG, Lake S. Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections.
Pediatrics. 2023;151(5). doi:10.1542/peds.2023-061585.
https://psnet.ahrq.gov/issue/explicitly-addressi…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/39860/psn-pdf
September 01, 2017 - Interventions to improve hand hygiene compliance in
patient care.
September 1, 2017
Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care.
Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4.
https://psnet.ahrq.gov/issue/interventions-i…
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psnet.ahrq.gov/node/860391/psn-pdf
January 10, 2024 - Neonatal near-miss audits: a systematic review and a call
to action.
January 10, 2024
Medeiros PB, Bailey C, Pollock D, et al. Neonatal near-miss audits: a systematic review and a call to
action. BMC Pediatr. 2023;23(1):573. doi:10.1186/s12887-023-04383-6.
https://psnet.ahrq.gov/issue/neonatal-near-miss-audits-sys…
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psnet.ahrq.gov/node/60954/psn-pdf
September 30, 2020 - Catheter-associated urinary tract infection reduction in a
pediatric safety engagement network.
September 30, 2020
Foster CB, Ackerman K, Hupertz V, et al. Catheter-associated urinary tract infection reduction in a pediatric
safety engagement network. Pediatrics. 2020;146(4):e20192057. doi:10.1542/peds.2019-2057.
…
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psnet.ahrq.gov/node/72763/psn-pdf
February 17, 2021 - Apotex Corp. issues voluntary nationwide recall of
Enoxaparin Sodium Injection, USP due to mislabeling of
syringe barrel measurement markings.
February 17, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 3. 2021.
https://psnet.ahrq.gov/issue/apotex-corp-issues…
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psnet.ahrq.gov/node/43114/psn-pdf
April 09, 2014 - The ethics of empowering patients as partners in
healthcare-associated infection prevention.
April 9, 2014
Sharp D, Palmore T, Grady C. The ethics of empowering patients as partners in healthcare-associated
infection prevention. Infect Control Hosp Epidemiol. 2014;35(3):307-9. doi:10.1086/675288.
https://psnet.ahr…
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psnet.ahrq.gov/node/40962/psn-pdf
December 14, 2011 - American College of Surgeons' Committee on Trauma
performance improvement and patient safety program:
maximal impact in a mature trauma center.
December 14, 2011
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma
Performance Improvement and Patient Safety program: …
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psnet.ahrq.gov/node/853442/psn-pdf
September 13, 2023 - Pediatric Diagnostic Safety: State of the Science and
Future Directions.
September 13, 2023
Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2023. AHRQ Publication No. 23-0040-5-EF.
https://psnet.ahrq.gov/issue/pediatric-diagnostic-safety-state-scienc…
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psnet.ahrq.gov/node/45246/psn-pdf
August 15, 2016 - Reliability of verbal handoff assessment and handoff
quality before and after implementation of a resident
handoff bundle.
August 15, 2016
Feraco AM, Starmer AJ, Sectish TC, et al. Reliability of Verbal Handoff Assessment and Handoff Quality
Before and After Implementation of a Resident Handoff Bundle. Acad Pediat…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apa_gtube.pdf
June 02, 2025 - NICU Toolkit, Appendix A, Gastrostomy Tube
Gastrostomy Tube (G Tube or Button)
Giving medicines and feeding if your baby has a
gastrostomy tube:
■ Clear the G tube or button as your health care provider showed you.
■ Check for placement of the G tube or button.
■ Slowly push in liquid medicine or feeding with…
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psnet.ahrq.gov/node/34914/psn-pdf
February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database.
February 27, 2009
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3…
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/45657/psn-pdf
March 08, 2017 - The causes of errors in clinical reasoning: cognitive
biases, knowledge deficits, and dual process thinking.
March 8, 2017
Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases,
Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30.
doi:10.1097/…
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psnet.ahrq.gov/node/46149/psn-pdf
June 28, 2017 - Clinical outcomes associated with medication regimen
complexity in older people: a systematic review.
June 28, 2017
Wimmer BC, Cross AJ, Jokanovic N, et al. Clinical Outcomes Associated with Medication Regimen
Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2016;65(4):747-753.
doi:10.1111/jgs.14…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/46795/psn-pdf
March 28, 2018 - Systematic review and meta-analysis of the effectiveness
of pharmacist-led medication reconciliation in the
community after hospital discharge.
March 28, 2018
McNab D, Bowie P, Ross A, et al. Systematic review and meta-analysis of the effectiveness of pharmacist-
led medication reconciliation in the community afte…