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  1. FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. | PSNet

    psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
    February 10, 2021 - 2018 Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  2. Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety? | PSNet

    psnet.ahrq.gov/issue/there-relationship-between-high-quality-performance-major-teaching-hospitals-and-residents
    July 21, 2010 - August 4, 2021 Transforming concepts in patient safety: a progress report. … November 26, 2014 Ten years after the IOM report: engaging residents in quality and patient … March 30, 2011 The impact of duty hours on resident self reports of errors.

  3. World Hand Hygiene Day. | PSNet

    psnet.ahrq.gov/issue/save-lives-clean-your-hands
    July 14, 2021 - Final Technical Report January 2009. … More Related Resources National and State Healthcare-Associated Infections Progress … Report.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38042/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. … ISMP medication error report analysis. Hosp Pharm. 2010;43(8):618-620. doi:10.1310/hpj4308- 618. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28 This monthly selection of medication … error reports addresses examples of unclear dose preparation instructions, potential insulin storage … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60173/psn-pdf
    March 30, 2020 - of what this report actually is?   … The prior reports were more hospital-focused, and we know that most care is not delivered there these … that haven’t been addressed in past reports? … I look at this report as a playbook. … AG: I was reflecting back on the first IOM report and the first Making Healthcare Safer Report and looking

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74172/psn-pdf
    December 08, 2021 - Differences in safety report event types submitted by graduate medical education trainees compared with … Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education … At one children’s hospital, graduate medical education (GME) trainees submitted reports of greater severity … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education-trainees-compared

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44480/psn-pdf
    October 14, 2015 - Improving radiology report quality by rapidly notifying radiologist of report errors. … Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors. … https://psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors … In this study, researchers designed an algorithm for flagging radiology reports that may contain gender … https://psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836966/psn-pdf
    April 20, 2022 - Performance variability in perioperative sentinel events: report on a nationwide data set. … Performance variability in perioperative sentinel events: report on a nationwide data set. … https://psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data … performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports … https://psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50795/psn-pdf
    January 15, 2020 - Diagnostic error in the emergency department: learning from national patient safety incident report … Diagnostic error in the emergency department: learning from national patient safety incident report … psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety- incident-report … This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency … psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36972/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. … ISMP medication error report analysis. Hosp Pharm. 2010;42(6):498-499. doi:10.1310/hpj4206- 498. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-14 This monthly selection of medication … error reports includes an error averted because the pharmacist checked the patient's prior prescription … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-14

  11. Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis. | PSNet

    psnet.ahrq.gov/issue/impact-cancelrx-discontinuation-controlled-substance-prescriptions-interrupted-time-series
    September 01, 2021 - long-term care for people with intellectual disability: an interrupted time series analysis of incident reports … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39470/psn-pdf
    January 09, 2024 - National Healthcare Quality and Disparities Reports. … https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports In this annual publication … , AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities … Report. … The 2023 report discusses the continued impact of COVID-19 on United States health care delivery.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852270/psn-pdf
    August 09, 2023 - Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. … https://psnet.ahrq.gov/issue/final-report-prioritization-patient-safety-practices-new-rapid-review-or-rapid … This report summarizes the results of the prioritization process used to identify patient safety practices … Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report … , including several practices that have not been covered in previous MHS reports (e.g., family/caregiver

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47292/psn-pdf
    May 01, 2022 - Nebraska Coalition for Patient Safety Annual Report. … https://psnet.ahrq.gov/issue/nebraska-coalition-patient-safety-2018-annual-report Patient Safety Organizations … This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected … between 2008 and 2021, offers insights drawn from an analysis of 1308 incident reports. … https://psnet.ahrq.gov/issue/nebraska-coalition-patient-safety-2018-annual-report https://psnet.ahrq.gov

  15. Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet

    psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent
    April 10, 2024 - Citation Related Resources From the Same Author(s) An analysis of incident reports … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 29, 2019 ISMP medication error report analysis.

  16. Lewis Blackman Patient Safety Award. | PSNet

    psnet.ahrq.gov/issue/lewis-blackman-patient-safety-award
    April 28, 2021 - Copy Citation Related Resources From the Same Author(s) CLER Report of Findings … April 14, 2021 ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient … November 18, 2020 National Report of Findings 2016: Issue Brief No. 2: Patient Safety … February 15, 2023 Differences in safety report event types submitted by graduate medical

  17. A Tale of Two Stories: Contrasting Views of Patient Safety. | PSNet

    psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
    March 27, 2005 - Book/Report Classic A Tale of Two Stories: Contrasting … A report from a workshop, this document is a well-written look at the differences between "first stories … December 24, 2008 MEDMARX Data Report: A Report on the Relationship of Drug Names and … Final Report. … View More Related Resources Adverse Health Events in Minnesota: Annual Reports

  18. Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet. | PSNet

    psnet.ahrq.gov/issue/healthcare-inspection-evaluation-veterans-health-administrations-national-consult-delay
    September 10, 2014 - Book/Report Healthcare Inspection: Evaluation of the Veterans Health Administration's … Report No. 14-04705-62. … Report No. 14-04705-62. … Report No. 14-04705-62. … May 1, 2015 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination

  19. Improving Patient Safety in Long-Term Care Facilities: Training Modules. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-long-term-care-facilities-training-modules
    August 17, 2022 - Book/Report Improving Patient Safety in Long-Term Care Facilities: Training Modules … May 7, 2014 Guide to Patient and Family Engagement: Environmental Scan Report. … February 28, 2025 National Healthcare Quality and Disparities Reports. … AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report … AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report

  20. Proceedings of a summit on preventing patient harm and death from IV medication errors. | PSNet

    psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
    June 16, 2019 - This article reports on the results of that conference along with ways to implement the suggested practices … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.
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