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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - characteristics of the technology are not carefully managed.(2,3)
The IT "Gap" Uncovered
Digital radiology (DR) represents
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Nurse staffing represents both a management and leadership responsibility, which encompasses the hiring
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - However, failure to do so represents a common
noncognitive error—an unconscious lapse in an automatic
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - from lithium is acquired NDI, occurring in approximately 40% of patients on chronic
lithium.(2) NDI represents
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Patient safety
reporting represents just one tool to promote patient safety.
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - continuous infusions via indwelling catheters.( 8 ) In summary, the addition of local/regional anesthesia represents
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psnet.ahrq.gov/node/41741/psn-pdf
October 10, 2012 - Improving America's Hospitals—The Joint Commission's
Annual Report on Quality and Safety.
October 10, 2012
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety
The Joint Commission's annual report summarizes hospital …
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psnet.ahrq.gov/node/46062/psn-pdf
December 19, 2017 - Frequency and nature of medication errors and adverse
drug events in mental health hospitals: a systematic
review.
December 19, 2017
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events
in mental health hospitals: a systematic review. Drug Saf. 2017;40(10):871-886. …
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psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Medication error prevention by clinical pharmacists in two
children's hospitals.
March 28, 2005
Folli HL; Poole RL; Benitz WE; Russo JC
https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
This prospective study recorded the rate and potential for harm caused by err…
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psnet.ahrq.gov/node/44911/psn-pdf
February 17, 2016 - Improving doctor–patient communication in a digital
world.
February 17, 2016
Lakshmanan I. The Diane Rehm Show. February 9, 2016.
https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world
Digital technologies represent both promise and risks for communication in health care. This radio inte…
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psnet.ahrq.gov/node/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
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psnet.ahrq.gov/node/46261/psn-pdf
July 18, 2018 - Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a patient-centered fall prevention toolkit.
July 18, 2018
Dykes PC, Duckworth M, Cunningham S, et al. Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a Patient-Centered Fall Prevention Toolkit. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/45934/psn-pdf
March 01, 2017 - The evolving role of medical scribe: variation and
implications for organizational effectiveness and safety.
March 1, 2017
Woodcock D, Pranaat R, McGrath K, et al. The Evolving Role of Medical Scribe: Variation and Implications
for Organizational Effectiveness and Safety. Stud Health Technol Inform. 2017;234:382-38…
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psnet.ahrq.gov/node/45716/psn-pdf
September 29, 2017 - Microanalysis of video from the operating room: an
underused approach to patient safety research.
September 29, 2017
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused
approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
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psnet.ahrq.gov/node/38716/psn-pdf
February 17, 2011 - Ending extra payment for "never events"—stronger
incentives for patients' safety.
February 17, 2011
Milstein A. Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med.
2009;360(23):2388-90. doi:10.1056/NEJMp0809125.
https://psnet.ahrq.gov/issue/ending-extra-payment-never-ev…
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psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
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psnet.ahrq.gov/node/45878/psn-pdf
September 20, 2017 - Development of a trigger tool to identify adverse events
and harm in emergency medical services.
September 20, 2017
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and
harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016-
20…
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psnet.ahrq.gov/node/35060/psn-pdf
November 04, 2015 - Risk factors for adverse drug events: a 10-year analysis.
November 4, 2015
Evans S, Lloyd JF, Stoddard GJ, et al. Risk factors for adverse drug events: a 10-year analysis. Ann
Pharmacother. 2005;39(7-8):1161-8.
https://psnet.ahrq.gov/issue/risk-factors-adverse-drug-events-10-year-analysis
Many medications remain a…
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psnet.ahrq.gov/node/34813/psn-pdf
July 10, 2008 - Hospital admissions due to adverse drug reactions: a
report from the Boston Collaborative Drug Surveillance
Program.
July 10, 2008
Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug
Surveillance Program. Arch Intern Med. 1974;134(2):219-23.
https://psnet.ahrq…