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psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication
March 13, 2012 - Study
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Citation Text:
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…
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psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
June 30, 2011 - Review
Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.
Citation Text:
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…
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psnet.ahrq.gov/issue/adverse-drug-event-rates-six-community-hospitals-and-potential-impact-computerized-physician
January 03, 2017 - Study
Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.
Citation Text:
Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the Potential Impact of Computerized Phys…
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psnet.ahrq.gov/issue/importance-safety-climate-teamwork-climate-and-demographics-understanding-nurses-allied
October 13, 2021 - Study
Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety.
Citation Text:
Zaheer S, Ginsburg LR, Wong HJ, et al. Importance of safety climate, teamwork climate and demographics…
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psnet.ahrq.gov/issue/human-factors-engineering-tool-medical-device-evaluation-hospital-procurement-decision-making
June 28, 2017 - Study
Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making.
Citation Text:
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. J Biomed Inform. 2005;38(3):213-9.
Copy C…
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psnet.ahrq.gov/issue/learning-preventable-adverse-events-health-care-organizations-development-multilevel-model
June 28, 2010 - Commentary
Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.
Citation Text:
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care organizations: development of a mu…
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psnet.ahrq.gov/issue/department-medicine-infrastructure-patient-safety-and-clinical-quality-improvement
July 01, 2017 - Review
A Department of Medicine infrastructure for patient safety and clinical quality improvement.
Citation Text:
Mathews SC, Pronovost P, Biddison LD, et al. A Department of Medicine Infrastructure for Patient Safety and Clinical Quality Improvement. Am J Med Qual. 2018;33(4):413-419. …
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psnet.ahrq.gov/issue/e-prescribing-and-adverse-drug-events-observational-study-medicare-part-d-population-diabetes
September 30, 2015 - Study
E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.
Citation Text:
Gabriel MH, Powers C, Encinosa W, et al. E-Prescribing and Adverse Drug Events: An Observational Study of the Medicare Part D Population With Diabetes. Med …
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psnet.ahrq.gov/issue/complexity-medication-related-verbal-orders
November 17, 2010 - Study
Complexity of medication-related verbal orders.
Citation Text:
Wakefield DS, Ward MM, Groath D, et al. Complexity of medication-related verbal orders. Am J Med Qual. 2008;23(1):7-17. doi:10.1177/1062860607310922.
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Format:
DOI Google Scholar PubMed BibTe…
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psnet.ahrq.gov/issue/practice-indicators-suboptimal-care-and-avoidable-adverse-events-content-analysis-national
May 13, 2015 - Study
Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination.
Citation Text:
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a natio…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotli…
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psnet.ahrq.gov/node/859347/psn-pdf
December 20, 2023 - Making surgery as safe as it should be: a qualitative
study.
December 20, 2023
Robinson DJ, Beaumont G. Making surgery as safe as it should be: a qualitative study. Am J Med Qual.
2023;38(5):238-244. doi:10.1097/jmq.0000000000000139.
https://psnet.ahrq.gov/issue/making-surgery-safe-it-should-be-qualitative-study
…
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psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention
February 10, 2011 - Study
Classic
Incidence of adverse drug events and potential adverse drug events: implications for prevention.
Citation Text:
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. …
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psnet.ahrq.gov/node/46397/psn-pdf
August 30, 2017 - Making Dialysis Safer for Patients Coalition.
August 30, 2017
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-dialysis-safer-patients-coalition
Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a
collective effort that aims to d…
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psnet.ahrq.gov/issue/increasing-patient-clinician-concordance-about-medical-error-disclosure-through-patient-tips
November 28, 2016 - Study
Increasing patient–clinician concordance about medical error disclosure through the patient TIPS model.
Citation Text:
Martinez W, Browning D, Varrin P, et al. Increasing Patient-Clinician Concordance About Medical Error Disclosure Through the Patient TIPS Model. J Patient Saf. 201…
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psnet.ahrq.gov/issue/self-reported-patient-safety-competence-among-new-graduates-medicine-nursing-and-pharmacy
February 14, 2015 - Study
Self-reported patient safety competence among new graduates in medicine, nursing and pharmacy.
Citation Text:
Ginsburg LR, Tregunno D, Norton PG. Self-reported patient safety competence among new graduates in medicine, nursing and pharmacy. BMJ Qual Saf. 2013;22(2):147-54. doi:10…
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psnet.ahrq.gov/issue/field-test-world-health-organization-multi-professional-patient-safety-curriculum-guide
June 04, 2014 - Study
Field test of the World Health Organization Multi-professional Patient Safety Curriculum Guide.
Citation Text:
Farley DO, Zheng H, Rousi E, et al. Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide. PLoS One. 2015;10(9):e0138510. doi:10.1…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/37755/psn-pdf
April 14, 2011 - An iconic language for the graphical representation of
medical concepts.
April 14, 2011
Lamy J-B, Duclos C, Bar-Hen A, et al. An iconic language for the graphical representation of medical
concepts. BMC Med Inform Decis Mak. 2008;8:16. doi:10.1186/1472-6947-8-16.
https://psnet.ahrq.gov/issue/iconic-language-graphi…