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psnet.ahrq.gov/node/39231/psn-pdf
January 13, 2010 - The Checklist Manifesto: How to Get Things Right.
January 13, 2010
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
https://psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through
his art…
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psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
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psnet.ahrq.gov/node/46098/psn-pdf
July 24, 2017 - Prospective evaluation of a multifaceted intervention to
improve outcomes in intensive care: the Promoting
Respect and Ongoing Safety through Patient Engagement
Communication and Technology study.
July 24, 2017
Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve
…
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psnet.ahrq.gov/node/73252/psn-pdf
January 01, 2022 - Why test results are still getting "lost" to follow-up: a
qualitative study of implementation gaps.
May 12, 2021
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative
study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
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psnet.ahrq.gov/node/37768/psn-pdf
April 27, 2010 - The wisdom and justice of not paying for "preventable
complications."
April 27, 2010
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable
complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197.
https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…
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psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
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psnet.ahrq.gov/node/46616/psn-pdf
July 02, 2019 - Medication-related clinical decision support alert
overrides in inpatients.
July 2, 2019
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in
inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
https://psnet.ahrq.gov/issue/medication-rel…
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psnet.ahrq.gov/node/40619/psn-pdf
October 06, 2016 - Sustaining and spreading the reduction of adverse drug
events in a multicenter collaborative.
October 6, 2016
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a
multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542/peds.2010-3772.
https://psnet.a…
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psnet.ahrq.gov/node/60552/psn-pdf
June 03, 2020 - Personal protective equipment for preventing highly
infectious diseases due to exposure to contaminated
body fluids in healthcare staff.
June 3, 2020
Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious
diseases due to exposure to contaminated body fluids in healthc…
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/45425/psn-pdf
December 22, 2018 - Automated identification of antibiotic overdoses and
adverse drug events via analysis of prescribing alerts and
medication administration records.
December 22, 2018
Kirkendall ES, Kouril M, Dexheimer JW, et al. Automated identification of antibiotic overdoses and adverse
drug events via analysis of prescribing ale…
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psnet.ahrq.gov/node/845278/psn-pdf
March 01, 2023 - Association between opioid tapering and subsequent
health care use, medication adherence, and chronic
condition control.
March 1, 2023
Magnan EM, Tancredi DJ, Xing G, et al. Association between opioid tapering and subsequent health care
use, medication adherence, and chronic condition control. JAMA Netw Open. 2023…
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psnet.ahrq.gov/node/46856/psn-pdf
June 20, 2018 - Visual acuity, literacy, and unintentional misuse of
nonprescription medications.
June 20, 2018
Mullen RJ, Curtis LM, O'Conor R, et al. Visual acuity, literacy, and unintentional misuse of nonprescription
medications. Am J Health-Syst Pharm. 2018;75(9):e213-e220. doi:10.2146/ajhp170303.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39641/psn-pdf
September 20, 2011 - Adherence to Surgical Care Improvement Project
measures and the association with postoperative
infections.
September 20, 2011
Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures
and the association with postoperative infections. JAMA. 2010;303(24):2479-85.
doi:10.1…
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psnet.ahrq.gov/node/44004/psn-pdf
September 01, 2016 - Impact of computerized physician order entry alerts on
prescribing in older patients.
September 1, 2016
Lester PE, Rios-Rojas L, Islam S, et al. Impact of computerized physician order entry alerts on prescribing
in older patients. Drugs Aging. 2015;32(3):227-33. doi:10.1007/s40266-015-0244-2.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/38536/psn-pdf
February 03, 2011 - Association between hospital-reported Leapfrog Safe
Practices scores and inpatient mortality.
February 3, 2011
Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13).
doi:10.1001/jama.2009.423.
https://psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-an…
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psnet.ahrq.gov/node/40393/psn-pdf
December 21, 2014 - Structured interdisciplinary rounds in a medical teaching
unit: improving patient safety.
December 21, 2014
O'Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit:
improving patient safety. Arch Intern Med. 2011;171(7):678-684. doi:10.1001/archinternmed.2011.128.
http…
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - The Financial and Human Cost of Medical Error... and
How Massachusetts Can Lead the Way on Patient Safety.
June 24, 2019
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-
way-patient-safety
The Betsy L…
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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - No Blood, Please
May 1, 2004
Liang BA. No Blood, Please. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/no-blood-please
The Case
A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the
emergency department (ED) via ambulance, where she was found to be suffering …
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…