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psnet.ahrq.gov/node/42360/psn-pdf
April 16, 2018 - Wrong-patient medication errors: an analysis of event
reports in Pennsylvania and strategies for prevention.
April 16, 2018
Yang A, Grissinger M. PA-PSRS Patient Saf Advis. June 2013;10:41-49.
https://psnet.ahrq.gov/issue/wrong-patient-medication-errors-analysis-event-reports-pennsylvania-and-
strategies-preventio…
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psnet.ahrq.gov/node/41480/psn-pdf
November 05, 2013 - Hospital patients' reports of medical errors and
undesirable events in their health care.
November 5, 2013
Davis R, Sevdalis N, Neale G, et al. Hospital patients' reports of medical errors and undesirable events in
their health care. J Eval Clin Pract. 2013;19(5):875-81. doi:10.1111/j.1365-2753.2012.01867.x.
https…
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psnet.ahrq.gov/node/42629/psn-pdf
October 02, 2013 - The relationship between the nursing work environment
and the occurrence of reported paediatric medication
administration errors: a pan Canadian study.
October 2, 2013
Sears K, O'Brien-Pallas L, Stevens B, et al. The Relationship Between the Nursing Work Environment and
the Occurrence of Reported Paediatric Medica…
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psnet.ahrq.gov/node/37264/psn-pdf
May 21, 2014 - Assessment of the AHRQ Patient Safety Initiative: Moving
from Research to Practice Evaluation Report II
(2003–2004).
May 21, 2014
Farley D, Morton SC, Damberg CL et al. Santa Monica, CA: Rand Corporation; 2007.
https://psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-moving-research-practice-evaluati…
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psnet.ahrq.gov/issue/report-burden-endemic-health-care-associated-infection-worldwide
November 02, 2022 - Book/Report
Report on the Burden of Endemic Health Care–Associated Infection Worldwide.
Citation Text:
Report on the Burden of Endemic Health Care–Associated Infection Worldwide. Allegranzi B, Nejad SB, Castillejos GG, Kilpatrick C, Kelley E, Mathai E; Clean Care is Safer Care Team. …
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psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
March 06, 2019 - Review
Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention.
Citation Text:
Stone AB, Urman RD, Kaye AD, et al. Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention. Curr Pain Headache Rep. 20…
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psnet.ahrq.gov/issue/natural-language-processing-approach-categorise-contributing-factors-patient-safety-event
April 26, 2023 - Study
A natural language processing approach to categorise contributing factors from patient safety event reports.
Citation Text:
A natural language processing approach to categorise contributing factors from patient safety event reports. Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Healt…
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psnet.ahrq.gov/node/42050/psn-pdf
January 07, 2015 - The association between frequency of self-reported
medical errors and anesthesia trainee supervision: a
survey of United States anesthesiology residents-in-
training.
January 7, 2015
De Oliveira GS, Rahmani R, Fitzgerald PC, et al. The association between frequency of self-reported
medical errors and anesthesia t…
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psnet.ahrq.gov/node/37486/psn-pdf
January 23, 2009 - Medication report reduces number of medication errors
when elderly patients are discharged from hospital.
January 23, 2009
Midlöv P, Holmdahl L, Eriksson T, et al. Medication report reduces number of medication errors when
elderly patients are discharged from hospital. Pharm World Sci. 2007;30(1):92-98. doi:10.1007…
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psnet.ahrq.gov/node/46143/psn-pdf
June 14, 2017 - Report of the Announced Inspection of Medication Safety
at the Midland Regional Hospital Tullamore, County
Offaly.
June 14, 2017
Dublin, Ireland: Health Information and Quality Authority; May 2017.
https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital-
tullamore-coun…
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psnet.ahrq.gov/node/44413/psn-pdf
October 07, 2015 - Improving transitions of care for patients on warfarin: the
Safe Transitions Anticoagulation Report.
October 7, 2015
Dunn AS, Shetreat-Klein A, Berman J, et al. Improving transitions of care for patients on warfarin: The safe
transitions anticoagulation report. J Hosp Med. 2015;10(9):615-8. doi:10.1002/jhm.2393.
h…
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psnet.ahrq.gov/node/40945/psn-pdf
November 23, 2011 - The nature and causes of unintended events reported at
10 internal medicine departments.
November 23, 2011
Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10
internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.1097/PTS.0b013e3182388f97.
https://…
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psnet.ahrq.gov/node/44300/psn-pdf
July 29, 2015 - Learning From Serious Failings in Care: Main Report.
July 29, 2015
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges
and Faculties in Scotland; May 2015.
https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
Substantive reports of failures have t…
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psnet.ahrq.gov/node/40165/psn-pdf
December 29, 2014 - Self-reported medical, medication and laboratory error in
eight countries: risk factors for chronically ill adults.
December 29, 2014
Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for
chronically ill adults. Int J Qual Health Care. 2011;23(2):182-6. doi:10.1093/in…
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psnet.ahrq.gov/issue/surveys-patient-safety-culture-sops-hospital-survey-20-user-database-report
December 18, 2024 - Book/Report
Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: User Database Report.
Citation Text:
Tyler ER, Yalden O, Fan L, et al. Surveys On Patient Safety Culture (Sops) Hospital Survey 2.0: User Database Report. Rockville, MD: Agency for Healthcare Research and Quality; …
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psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
December 18, 2019 - Study
Emerging Classic
Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.
Citation Text:
Härkänen M, Turunen H, Vehviläine…
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psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
May 04, 2022 - Study
Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.
Citation Text:
Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…
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psnet.ahrq.gov/node/45184/psn-pdf
June 01, 2016 - Measuring patient safety in primary care: the
development and validation of the "Patient Reported
Experiences and Outcomes of Safety in Primary Care"
(PREOS-PC).
June 1, 2016
Ricci-Cabello I, Avery A, Reeves D, et al. Measuring Patient Safety in Primary Care: The Development and
Validation of the "Patient Reporte…
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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/38804/psn-pdf
July 22, 2009 - Tenfold therapeutic dosing errors in young children
reported to US poison control centers.
July 22, 2009
Crouch BI, Caravati M, Moltz E. Tenfold therapeutic dosing errors in young children reported to U.S. poison
control centers. Am J Health Syst Pharm. 2009;66(14):1292-6. doi:10.2146/080377.
https://psnet.ahrq.go…