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psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
December 24, 2008 - Book/Report
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Citation Text:
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health C…
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psnet.ahrq.gov/issue/understanding-national-coverage-policies-navigating-maze-hacs-serious-reportable-events-and
June 28, 2017 - Commentary
Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites.
Citation Text:
Cook J, D'Amato C, Garrett G, et al. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, a…
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psnet.ahrq.gov/issue/charter-professionalism-health-care-organizations
May 25, 2016 - Commentary
The Charter on Professionalism for Health Care Organizations.
Citation Text:
Egener BE, Mason DJ, McDonald WJ, et al. The Charter on Professionalism for Health Care Organizations. Acad Med. 2017;92(8):1091-1099. doi:10.1097/ACM.0000000000001561.
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psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
May 13, 2009 - Commentary
Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.
Citation Text:
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…
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psnet.ahrq.gov/issue/variability-concentrations-intravenous-drug-infusions-prepared-critical-care-unit
March 02, 2011 - Study
Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.
Citation Text:
Wheeler DW, Degnan BA, Sehmi JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med. 2008;34(8…
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psnet.ahrq.gov/issue/development-conceptual-map-negative-consequences-patients-overuse-medical-tests-and
November 01, 2017 - Commentary
Emerging Classic
Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments.
Citation Text:
Korenstein D, Chimonas S, Barrow B, et al. Development of a Conceptual Map of Negative Consequences for P…
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psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
July 23, 2010 - Commentary
Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.
Citation Text:
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …
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psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence-based-evaluation
July 14, 2010 - Commentary
Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.
Citation Text:
Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework.…
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psnet.ahrq.gov/issue/patient-safety-ten-unmistakable-progress-troubling-gaps
March 02, 2011 - Commentary
Classic
Patient safety at ten: unmistakable progress, troubling gaps.
Citation Text:
Wachter R. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29(1):165-173. doi:10.1377/hlthaff.2009.0785.
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psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
February 02, 2022 - Study
Child-specific risk factors and patient safety.
Citation Text:
Child-specific risk factors and patient safety. Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22.
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psnet.ahrq.gov/issue/engaging-patient-and-family-surgical-safety-process-utilizing-safestart
October 19, 2022 - Study
Engaging the patient and family in the surgical safety process utilizing SafeStart.
Citation Text:
Elger BM, Esparaz JR, Nierstedt RT, et al. Engaging the patient and family in the surgical safety process utilizing. J Pediatr Surg. 2020;55(4). doi:10.1016/j.jpedsurg.2019.06.012.
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psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
April 08, 2020 - Press Release/Announcement
Wear face masks with no metal during MRI exams.
Citation Text:
Wear face masks with no metal during MRI exams. FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.
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psnet.ahrq.gov/issue/comparing-trainee-and-staff-perceptions-patient-safety-culture
February 15, 2017 - Study
Comparing trainee and staff perceptions of patient safety culture.
Citation Text:
Bump GM, Coots N, Liberi CA, et al. Comparing Trainee and Staff Perceptions of Patient Safety Culture. Acad Med. 2017;92(1):116-122. doi:10.1097/ACM.0000000000001255.
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psnet.ahrq.gov/issue/thoughtless-design-electronic-health-record-drives-overuse-purposeful-design-can-nudge
July 17, 2024 - Commentary
Emerging Classic
Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care.
Citation Text:
Vaughn VM, Linder JA. Thoughtless design of the electronic health record drives overuse, but purp…
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psnet.ahrq.gov/issue/promoting-health-care-safety-through-training-high-reliability-teams
January 06, 2018 - Commentary
Promoting health care safety through training high reliability teams.
Citation Text:
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.
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psnet.ahrq.gov/issue/safety-warnings-regarding-use-fentanyl-transdermal-skin-patches
August 12, 2015 - Government Resource
Fentanyl transdermal system (marketed as Duragesic) information.
Citation Text:
Fentanyl transdermal system (marketed as Duragesic) information. US Food and Drug Administration. MedWatch. July 10, 2015.
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psnet.ahrq.gov/issue/managing-discontinuity-academic-medical-centers-strategies-safe-and-effective-resident-sign
November 26, 2014 - Review
Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
Citation Text:
Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. J Hosp…
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psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
October 28, 2009 - Study
The impact of duty hours on resident self reports of errors.
Citation Text:
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J Gen Intern Med. 2007;22(2):205-9.
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psnet.ahrq.gov/issue/addressing-elephant-room-shame-resilience-seminar-medical-students
June 07, 2023 - Commentary
Addressing the elephant in the room: a shame resilience seminar for medical students.
Citation Text:
Bynum WE, Adams A, Edelman CE, et al. Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students. Acad Med. 2019;94(8):1132-1136. doi:10.1097/ACM.0000…
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - Commentary
Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.
Citation Text:
Flemming DJ, White C, Fox E, et al. Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. Skeletal Radiol. 2023;52(3):493-503. doi:10.1007/s00256-022-04…