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psnet.ahrq.gov/node/60347/psn-pdf
January 01, 2021 - Patient safety education 20 years after the Institute of
Medicine report: results from a cross-sectional national
survey.
May 20, 2020
Arora S, Tsang F, Kekecs Z, et al. Patient safety education 20 years after the Institute of Medicine report:
results from a cross-sectional national survey. J Patient Saf. 2021;17(…
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psnet.ahrq.gov/node/50886/psn-pdf
February 12, 2020 - Identifying risks areas related to medication
administrations - text mining analysis using free-text
descriptions of incident reports.
February 12, 2020
Härkänen M, Paananen J, Murrells T, et al. Identifying risks areas related to medication administrations -
text mining analysis using free-text descriptions of in…
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psnet.ahrq.gov/node/42232/psn-pdf
May 08, 2013 - The Measurement and Monitoring of Safety.
May 8, 2013
Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447.
https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety
Despite great effort, health care organizations are still learning how to identify safety problems, es…
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psnet.ahrq.gov/node/37989/psn-pdf
August 13, 2008 - New patient safety organizations lower roadblocks to
medical error reporting.
August 13, 2008
Clancy CM. New patient safety organizations lower roadblocks to medical error reporting. Am J Med Qual.
2008;23(4):318-21. doi:10.1177/1062860608319673.
https://psnet.ahrq.gov/issue/new-patient-safety-organizations-lower-…
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psnet.ahrq.gov/node/43675/psn-pdf
April 18, 2016 - Patient Safety 2015: Final Technical Report.
April 18, 2016
Washington, DC: National Quality Forum; 2016.
https://psnet.ahrq.gov/issue/patient-safety-2015-final-technical-report
The value of current measures to track patient safety has been called into question. This technical report
provides information about a c…
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psnet.ahrq.gov/node/39028/psn-pdf
October 21, 2009 - The content and context of change of shift report on
medical and surgical units.
October 21, 2009
Staggers N, Jennings BM. The content and context of change of shift report on medical and surgical units.
J Nurs Adm. 2009;39(9):393-8. doi:10.1097/NNA.0b013e3181b3b63a.
https://psnet.ahrq.gov/issue/content-and-contex…
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psnet.ahrq.gov/issue/decreasing-patient-misidentification-chemotherapy-administration
July 19, 2023 - Commentary
Decreasing patient misidentification before chemotherapy administration.
Citation Text:
Spruill A, Eron B, Coghill A, et al. Decreasing patient misidentification before chemotherapy administration. Clin J Oncol Nurs. 2009;13(6):716-7. doi:10.1188/09.CJON.716-717.
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
December 21, 2022 - Book/Report
Malnutrition in Hospitalized Adults: A Systematic Review.
Citation Text:
Malnutrition in Hospitalized Adults: A Systematic Review. Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. AHRQ Publication No. 21(22)…
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psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative
August 01, 2012 - Government Resource
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative.
Citation Text:
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13…
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psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
May 16, 2018 - Book/Report
DOD Should Improve Its Process for Clinical Adverse Actions against Providers.
Citation Text:
DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
…
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psnet.ahrq.gov/issue/report-safe-use-pick-lists-ambulatory-care-settings
June 29, 2016 - Government Resource
Report on the Safe Use of Pick Lists in Ambulatory Care Settings.
Citation Text:
Report on the Safe Use of Pick Lists in Ambulatory Care Settings. Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
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…
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psnet.ahrq.gov/issue/selecting-safe-and-easier-use-products-healthcare-using-human-factors-specification-and
February 21, 2018 - Book/Report
Selecting Safe and Easier to Use Products for Healthcare Using Human Factors Specification and Checklists.
Citation Text:
Selecting Safe and Easier to Use Products for Healthcare Using Human Factors Specification and Checklists. Buckinghamshire, UK. Clinical Human Facto…
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psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdose-de-morphine-resultant-de
January 13, 2016 - Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Citation Text:
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant …
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psnet.ahrq.gov/issue/electronically-generated-medication-administration-and-electronic-medication-administration
May 25, 2016 - Book/Report
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Citation Text:
Electronically Generated Medication Administration and Electr…
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psnet.ahrq.gov/issue/identity-crisis-examination-costs-and-benefits-unique-patient-identifier-us-health-care
May 21, 2014 - Book/Report
Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System.
Citation Text:
Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System. Hillestad R, Bigelow …
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psnet.ahrq.gov/issue/medication-safety-look-alike-sound-alike-medicines
November 19, 2014 - Book/Report
Medication Safety for Look-alike, Sound-alike Medicines.
Citation Text:
Medication Safety for Look-alike, Sound-alike Medicines. Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.
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…
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psnet.ahrq.gov/issue/designing-strategy-promote-safe-innovative-label-use-medications
May 06, 2009 - Commentary
Designing a strategy to promote safe, innovative off-label use of medications.
Citation Text:
Ansani N, Sirio CA, Smitherman T, et al. Designing a strategy to promote safe, innovative off-label use of medications. Am J Med Qual. 2006;21(4):255-261.
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Format…
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psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century
July 08, 2016 - Book/Report
Classic
Crossing the Quality Chasm: A New Health System for the 21st Century.
Citation Text:
Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: N…
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psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-pulse-survey-march-23-27
December 23, 2020 - Book/Report
Classic
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.
Citation Text:
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. Was…