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psnet.ahrq.gov/node/848041/psn-pdf
April 26, 2023 - Potentiality of algorithms and artificial intelligence
adoption to improve medication management in primary
care: a systematic review.
April 26, 2023
Damiani G, Altamura G, Zedda M, et al. Potentiality of algorithms and artificial intelligence adoption to
improve medication management in primary care: a systematic…
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psnet.ahrq.gov/node/841475/psn-pdf
January 01, 2023 - The second victim of unanticipated adverse events.
December 14, 2022
Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac
Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010.
https://psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events
“Se…
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psnet.ahrq.gov/issue/patient-safety-climate-strength-concept-requires-more-attention
March 04, 2011 - Study
Patient safety climate strength: a concept that requires more attention.
Citation Text:
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/38032/psn-pdf
September 21, 2008 - Medication errors in the ambulatory treatment of pediatric
attention deficit hyperactivity disorder.
September 21, 2008
Bundy DG, Rinke ML, Shore AD, et al. Medication errors in the ambulatory treatment of pediatric attention
deficit hyperactivity disorder. Jt Comm J Qual Patient Saf. 2008;34(9):552-559, 497.
http…
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psnet.ahrq.gov/node/35410/psn-pdf
September 11, 2009 - Intravenous medication safety and smart infusion
systems: lessons learned and future opportunities.
September 11, 2009
Keohane C, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems: lessons
learned and future opportunities. J Infus Nurs. 2005;28(5):321-328.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/866692/psn-pdf
September 11, 2024 - Relationships between medications used in a mental
health hospital and types of medication errors: a cross-
sectional study over an 8-year period.
September 11, 2024
Lebas R, Calvet B, Schadler L, et al. Relationships between medications used in a mental health hospital
and types of medication errors: a cross-sect…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - The nature, severity and causes of medication incidents
from an Australian community pharmacy incident
reporting system: the QUMwatch study.
July 28, 2021
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an
Australian community pharmacy incident reporting system: T…
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Undiagnosed Vaginal Bleeding
Citation Text:
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/37132/psn-pdf
June 14, 2011 - Preventing medication errors in community pharmacy:
root-cause analysis of transcription errors.
June 14, 2011
Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-
cause analysis of transcription errors. Qual Saf Health Care. 2007;16(4):285-90.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Defenses could be built in at many stages, depending on the outcome of the investigation.
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psnet.ahrq.gov/node/837677/psn-pdf
July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient
Diagnosed with Prostate Cancer at the Hampton VA
Medical Center in Virginia.
July 13, 2022
Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.
https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-…
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psnet.ahrq.gov/node/836829/psn-pdf
March 30, 2022 - Safety in fragile, conflict-affected, and vulnerable
settings: An evidence scanning approach for identifying
patient safety interventions.
March 30, 2022
O’Brien N, Shaw A, Flott K, et al. Safety in fragile, conflict-affected, and vulnerable settings: an evidence
scanning approach for identifying patient safety in…
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psnet.ahrq.gov/node/43366/psn-pdf
March 04, 2015 - Safety of medication use in primary care.
March 4, 2015
Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract.
2015;23(1):3-20. doi:10.1111/ijpp.12120.
https://psnet.ahrq.gov/issue/safety-medication-use-primary-care
This systematic review found that incidence rates of…
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/node/73146/psn-pdf
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis
Dialysis Care and Patient Safety Concerns
In patients with chronic kidney disease, kidney function declines ov…
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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…
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psnet.ahrq.gov/node/41541/psn-pdf
September 26, 2012 - Failures in communication and information transfer
across the surgical care pathway: interview study.
September 26, 2012
Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical
care pathway: interview study. BMJ Qual Saf. 2012;21(10):843-9.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47935/psn-pdf
April 17, 2019 - Teaching patient safety in global health: lessons from the
Duke Global Health Patient Safety Fellowship.
April 17, 2019
Johnston BE, Lou-Meda R, Mendez S, et al. Teaching patient safety in global health: lessons from the
Duke Global Health Patient Safety Fellowship. BMJ Glob Health. 2019;4(1). doi:10.1136/bmjgh-201…
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psnet.ahrq.gov/node/837793/psn-pdf
August 10, 2022 - The effect of structured medication review followed by
face-to-face feedback to prescribers on adverse drug
events recognition and prevention in older inpatients - a
multicenter interrupted time series study.
August 10, 2022
Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect of structured medication review f…