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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - November 16, 2015
Evaluation of a Web-based education program on reducing medication
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - In July 2003, the
Accreditation Council for Graduate Medical Education (ACGME) implemented mandates reducing
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - Reducing the rate of repeat imaging: import of
outside images to PACS.
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Reducing
complexity by simplifying protocols and operations can decrease errors and prevent adverse
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - defense against medication errors, and ward-based clinical
pharmacists can be particularly valuable by reducing
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - Treatment is critical for reducing the adverse health, social, and other consequences of alcohol use
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - made extensive progress in changing the culture in hospitals and other health care institutions and in reducing … And the report shows that there has been very little progress in reducing disparities, although the disparities … Funding Opportunity Announcement describing our interest in funding grants that will make progress in reducing
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psnet.ahrq.gov/node/73971/psn-pdf
October 13, 2021 - Safety culture as a patient safety practice for alarm
fatigue.
October 13, 2021
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA.
2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
https://psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fati…
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psnet.ahrq.gov/node/836864/psn-pdf
April 06, 2022 - Improving the specificity of drug-drug interaction alerts:
can it be done?
April 6, 2022
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am
J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
https://psnet.ahrq.gov/issue/improving-specif…
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psnet.ahrq.gov/node/45910/psn-pdf
March 08, 2017 - Electronically Generated Medication Administration and
Electronic Medication Administration Records for the
Prevention of Medication Transcription Errors: Review of
Clinical Effectiveness and Safety.
March 8, 2017
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39615/psn-pdf
December 17, 2010 - Computerized decision support for medication dosing in
renal insufficiency: a randomized, controlled trial.
December 17, 2010
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal
insufficiency: a randomized, controlled trial. Ann Emerg Med. 2010;56(6):623-9.
doi:10.10…
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psnet.ahrq.gov/node/40490/psn-pdf
June 01, 2011 - Standardized multidisciplinary protocol improves
handover of cardiac surgery patients to the intensive care
unit.
June 1, 2011
Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac
surgery patients to the intensive care unit*. Pediatric Critical Care Medicine. 2010…
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psnet.ahrq.gov/node/47954/psn-pdf
August 07, 2019 - Special Issue on Resilience Engineering and High
Reliability Organizations.
August 7, 2019
Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533.
https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
Resilience is an organizational characteristic that enables indivi…
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psnet.ahrq.gov/node/867450/psn-pdf
January 08, 2025 - Advancing Health Care Safety for All.
January 8, 2025
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
https://psnet.ahrq.gov/issue/advancing-health-care-safety-all
As one element of a national program to improve care quality, the Centers for Medicare and Medicaid
Services (C…
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psnet.ahrq.gov/node/34979/psn-pdf
June 22, 2009 - The WHO World Alliance for Patient Safety: a new
challenge or an old one neglected?
June 22, 2009
Edwards R. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Drug
Saf. 2005;28(5):379-86.
https://psnet.ahrq.gov/issue/who-world-alliance-patient-safety-new-challenge-or-old-one-negle…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - Medication errors: the year in review: January through
December 2021.
January 11, 2023
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur despite long-standing efforts to redu…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/60742/psn-pdf
July 29, 2020 - Doctors and dentists still flooding U.S. with opioid
prescriptions.
July 29, 2020
Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July
17.
https://psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions
Despite efforts to reduce opio…
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psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…