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psnet.ahrq.gov/node/36809/psn-pdf
May 04, 2015 - Hospitals target risks of color wristbands.
May 4, 2015
Landro L.
https://psnet.ahrq.gov/issue/hospitals-target-risks-color-wristbands
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid
confusion and reduce the risk of error.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/36153/psn-pdf
August 02, 2006 - Frederick mother's burning inspires daughter's activism.
August 2, 2006
Levine S.
https://psnet.ahrq.gov/issue/frederick-mothers-burning-inspires-daughters-activism
This article reports on the efforts of one woman, whose mother was severely burned during a
tracheostomy, to educate others about and reduce the risk …
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psnet.ahrq.gov/node/35260/psn-pdf
January 25, 2010 - The enterprise take on patient safety.
January 25, 2010
Rogoski RR. The enterprise take on patient safety. Health management technology. 2005;26(8):12, 14, 16-
7.
https://psnet.ahrq.gov/issue/enterprise-take-patient-safety
This article reports on two efforts to reduce medical errors through information technology …
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - improved work environments for nurses, which may augment patient outcomes by enhancing teamwork and reducing
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - additional suggestions on how to minimize alert fatigue in CPOE systems: Increase alert specificity by reducing
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - the ways in which their thinking fails (meta-
cognition) may offer one of the best strategies for reducing
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - individual patient
Default settings may not make sense for every patient
21
21
Role of Institutions in Reducing
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - of breed EDIS product.( 8 ) An integrated electronic medical record (EMR) is only one step toward reducing
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - The changes to the alarm system have shown promising results for reducing alarm frequency and duration … Reducing ICU utilization, length of stay, and cost by optimizing the clinical use of continuous monitoring … 2023
Journal Article
Study
Reducing
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - orientation, with a focus on safety; better ongoing training; improvement of infrastructure (such as reducing
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Proper planning and execution of the CABG operation has been
shown to prolong life by reducing rates
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psnet.ahrq.gov/node/38845/psn-pdf
August 05, 2009 - Hospitals tally their avoidable mistakes.
August 5, 2009
Rein L. Washington Post. July 21, 2009:E1.
https://psnet.ahrq.gov/issue/hospitals-tally-their-avoidable-mistakes
This news article reports on Washington, DC–area initiatives to track preventable patient injury and
discusses strategies to hold hospitals accou…
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psnet.ahrq.gov/node/42478/psn-pdf
August 07, 2013 - A guide for HCAs on safe patient transfers.
August 7, 2013
Lees L.
https://psnet.ahrq.gov/issue/guide-hcas-safe-patient-transfers
This commentary offers practical advice for health care assistants to reduce risks during patient transfers.
https://psnet.ahrq.gov/issue/guide-hcas-safe-patient-transfers
https://psnet…
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psnet.ahrq.gov/node/37305/psn-pdf
January 02, 2011 - Medication administration in anesthesia: time for a
paradigm shift.
January 2, 2011
Stabile M; Webster CS; Merry AF.
https://psnet.ahrq.gov/issue/medication-administration-anesthesia-time-paradigm-shift
To reduce anesthesia administration errors, the authors propose changing the organizational culture to
foster a…
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psnet.ahrq.gov/node/37574/psn-pdf
February 27, 2008 - Patient safety: the synergy of technology and behavior.
February 27, 2008
Yarbrough C, Rypkema S. Patient Saf Qual Healthc. January/February 2008.
https://psnet.ahrq.gov/issue/patient-safety-synergy-technology-and-behavior
This article describes how one Veterans Affairs hospital employed teamwork, checklists, and t…
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psnet.ahrq.gov/node/34905/psn-pdf
February 25, 2009 - On the quest for Six Sigma.
February 25, 2009
Moorman D. On the quest for Six Sigma. Am J Surg. 2005;189(3):253-8.
https://psnet.ahrq.gov/issue/quest-six-sigma
This discussion of patient safety from a surgical perspective highlights issues involving hierarchy, human
factors, and multidisciplinary team training as …
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psnet.ahrq.gov/node/41475/psn-pdf
June 20, 2012 - Behind one hospital's fight against deadly infection.
June 20, 2012
Landro L.
https://psnet.ahrq.gov/issue/behind-one-hospitals-fight-against-deadly-infection
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
https://psnet.ahrq.gov/issue/behind-one-hospitals-fight-against…
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psnet.ahrq.gov/node/40299/psn-pdf
April 16, 2018 - Medication errors in the emergency department: need for
pharmacy involvement?
April 16, 2018
https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
This piece reports on the prevalence of medication errors in the emergency department and suggests
expanding pharmacy involvemen…
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - support for healthcare workers involved in adverse events by ensuring that resources are available for reducing