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psnet.ahrq.gov/node/41884/psn-pdf
December 21, 2014 - Supratherapeutic dosing of acetaminophen among
hospitalized patients.
December 21, 2014
Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized
patients. Arch Intern Med. 2012;172(22):1721-8.
https://psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospit…
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psnet.ahrq.gov/node/867335/psn-pdf
December 11, 2024 - Comparing safety, performance and user perceptions of a
patient-specific indication-based prescribing tool with
current practice: a mixed methods randomised user
testing study.
December 11, 2024
Feather C, Clarke J, Appelbaum N, et al. Comparing safety, performance and user perceptions of a patient-
specific indi…
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psnet.ahrq.gov/node/36807/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Fourth Annual Patient Safety
in American Hospitals Study.
October 25, 2013
Denver, CO; Health Grades Inc; 2007.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-fourth-annual-patient-safety-american-hospitals-
study
This fourth annual report on the safety of hospitalized Medicar…
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psnet.ahrq.gov/node/38760/psn-pdf
July 08, 2009 - Nurses' perceptions of safety culture in long-term care
settings.
July 8, 2009
Wagner LM, Capezuti E, Rice JC. Nurses' perceptions of safety culture in long-term care settings. J Nurs
Scholarsh. 2009;41(2):184-192. doi:10.1111/j.1547-5069.2009.01270.x.
https://psnet.ahrq.gov/issue/nurses-perceptions-safety-culture…
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psnet.ahrq.gov/node/846160/psn-pdf
March 15, 2023 - Critical care teamwork in the future: the role of
TeamSTEPPS in the COVID-19 pandemic and implications
for the future.
March 15, 2023
Terregino CA, Jagpal S, Parikh P, et al. Critical Care Teamwork in the Future: The Role of Critical care
teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and …
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psnet.ahrq.gov/node/42575/psn-pdf
September 26, 2016 - Are interventions to reduce interruptions and errors
during medication administration effective?: a systematic
review.
September 26, 2016
Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication
administration effective?: a systematic review. BMJ Qual Saf. 2014;23(5):414-21. d…
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psnet.ahrq.gov/node/46361/psn-pdf
May 23, 2018 - Inadequate hand-off communication.
May 23, 2018
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
https://psnet.ahrq.gov/issue/inadequate-hand-communication
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety
issues and provide guidelines fo…
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psnet.ahrq.gov/node/848040/psn-pdf
April 26, 2023 - Impact of work schedules of senior resident physicians
on patient and resident physician safety: nationwide,
prospective cohort study.
April 26, 2023
Barger LK, Weaver MD, Sullivan JP, et al. Impact of work schedules of senior resident physicians on
patient and resident physician safety: nationwide, prospective co…
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psnet.ahrq.gov/node/41935/psn-pdf
December 19, 2012 - Results of an effort to integrate quality and safety into
medical and nursing school curricula and foster joint
learning.
December 19, 2012
Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and
nursing school curricula and foster joint learning. Health Aff (…
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psnet.ahrq.gov/node/866320/psn-pdf
January 01, 2025 - Rapid response systems, antibiotic stewardship and
medication reconciliation: a scoping review on
implementation factors, activities and outcomes.
July 17, 2024
Ohlsen JT, Søfteland E, Akselsen PE, et al. Rapid response systems, antibiotic stewardship and
medication reconciliation: a scoping review on implementati…
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psnet.ahrq.gov/node/36836/psn-pdf
January 29, 2015 - Learning from Bristol: The Report of the Public Inquiry
into Children's Heart Surgery at the Bristol Royal
Infirmary 1984--1995.
January 29, 2015
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-child…
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psnet.ahrq.gov/node/40473/psn-pdf
July 02, 2011 - A systematic review of failures in handoff communication
during intrahospital transfers.
July 2, 2011
Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers.
Jt Comm J Qual Patient Saf. 2011;37(6):274-284.
https://psnet.ahrq.gov/issue/systematic-review-failures-h…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
November 1, 2018
Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
Perspective
In this month's PSNet perspective, I interview Dr. David M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of