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psnet.ahrq.gov/node/50688/psn-pdf
November 20, 2019 - Roles and role ambiguity in patient- and caregiver-
performed outpatient parenteral antimicrobial therapy.
November 20, 2019
Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed
Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763…
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psnet.ahrq.gov/node/837417/psn-pdf
June 15, 2022 - A blueprint for success: implementation of the Center for
Medicare and Medicaid Services mandated
anesthesiology oversight for procedural sedation in a
large health system.
June 15, 2022
Abdelmalak BB, Adhami T, Simmons W, et al. A blueprint for success: implementation of the Center for
Medicare and Medicaid Serv…
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psnet.ahrq.gov/node/47258/psn-pdf
January 09, 2019 - The effect of cognitive load and task complexity on
automation bias in electronic prescribing.
January 9, 2019
Lyell D, Magrabi F, Coiera E. The Effect of Cognitive Load and Task Complexity on Automation Bias in
Electronic Prescribing. Hum Factors. 2018;60(7):1008-1021. doi:10.1177/0018720818781224.
https://psnet.…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…
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psnet.ahrq.gov/node/36433/psn-pdf
February 10, 2011 - Effects of computer-based clinical decision support
systems on physician performance and patient outcomes:
a systematic review.
February 10, 2011
Hunt DL, Haynes RB, Hanna SE, et al. Effects of Computer-Based Clinical Decision Support Systems on
Physician Performance and Patient Outcomes. JAMA. 2003;280(15):1339-1…
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psnet.ahrq.gov/node/47453/psn-pdf
May 20, 2019 - Patient safety and the ageing physician: a qualitative
study of key stakeholder attitudes and experiences.
May 20, 2019
White AA, Sage WM, Osinska PH, et al. Patient safety and the ageing physician: a qualitative study of key
stakeholder attitudes and experiences. BMJ Qual Saf. 2019;28(6):468-475. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/46456/psn-pdf
February 28, 2018 - Drug calculation ability of qualified paramedics: a pilot
study.
February 28, 2018
Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med.
2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006.
https://psnet.ahrq.gov/issue/drug-calculation-ability-qualified-par…
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psnet.ahrq.gov/node/35251/psn-pdf
April 06, 2011 - Promoting health care safety through training high
reliability teams.
April 6, 2011
Wilson KA. Promoting health care safety through training high reliability teams. Quality and Safety in Health
Care. 2005;14(4). doi:10.1136/qshc.2004.010090.
https://psnet.ahrq.gov/issue/promoting-health-care-safety-through-trainin…
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psnet.ahrq.gov/node/74116/psn-pdf
November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an
Optimal Clinical Learning Environment to Achieve Safe
and High-Quality Patient Care, 2021.
November 24, 2021
Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN:
9781945365416.
https://psnet.ahrq.gov/issue/ncicle-pathwa…
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psnet.ahrq.gov/node/46447/psn-pdf
September 27, 2017 - Creating highly reliable accountable care organizations.
September 27, 2017
Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev.
2016;73(6):660-672.
https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations
High reliability is a goal throughout …
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psnet.ahrq.gov/node/854255/psn-pdf
October 04, 2023 - Empowering telemetry technicians and enhancing
communication to improve in-hospital cardiac arrest
survival.
October 4, 2023
McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to
improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/44391/psn-pdf
January 22, 2016 - Safety culture in cardiac surgical teams: data from five
programs and national surgical comparison.
January 22, 2016
Marsteller JA, Wen M, Hsu Y-J, et al. Safety Culture in Cardiac Surgical Teams: Data From Five Programs
and National Surgical Comparison. Ann Thorac Surg. 2015;100(6):2182-9.
doi:10.1016/j.athoracsu…
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psnet.ahrq.gov/node/40984/psn-pdf
September 01, 2016 - Provider and pharmacist responses to warfarin drug–drug
interaction alerts: a study of healthcare downstream of
CPOE alerts.
September 1, 2016
Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug
interaction alerts: a study of healthcare downstream of CPOE alerts. J Am Med …
-
psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/41561/psn-pdf
August 01, 2012 - Few Adverse Events in Hospitals Were Reported to State
Adverse Event Reporting Systems.
August 1, 2012
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
July 2012. Report No. OEI-06-09-00092.
https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reporte…
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psnet.ahrq.gov/node/45845/psn-pdf
December 19, 2017 - You can't blame the wreck on the train.
December 19, 2017
Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978.
doi:10.1016/j.amjsurg.2016.11.046.
https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train
Insufficient supervision can limit resident education, which may increase risks to p…
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psnet.ahrq.gov/node/44406/psn-pdf
December 04, 2016 - Drug manufacturers' delayed disclosure of serious and
unexpected adverse events to the US Food and Drug
Administration.
December 4, 2016
Ma P, Marinovic I, Karaca-Mandic P. Drug Manufacturers' Delayed Disclosure of Serious and Unexpected
Adverse Events to the US Food and Drug Administration. JAMA Intern Med. 2015;…
-
psnet.ahrq.gov/node/46475/psn-pdf
April 16, 2018 - Incident reporting behaviours following the Francis
report: a cross-sectional survey.
April 16, 2018
Archer G, Colhoun A. Incident reporting behaviours following the Francis report: A cross-sectional survey. J
Eval Clin Pract. 2017;24(2). doi:10.1111/jep.12849.
https://psnet.ahrq.gov/issue/incident-reporting-behav…
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psnet.ahrq.gov/node/866254/psn-pdf
July 10, 2024 - Top Penn State Health surgeon warned leaders about
transplant problems months before shutdown. Then he
was let go.
July 10, 2024
Massey W, Keith C. Spotlight PA: June 20, 2024.
https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-
months-shutdown-then
Whistleblowers…