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psnet.ahrq.gov/issue/procon-debate-color-coded-medication-labels
December 23, 2008 - Newspaper/Magazine Article
Pro/con debate: color-coded medication labels.
Citation Text:
Pro/con debate: color-coded medication labels. Janik LS, Vender JS, Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
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psnet.ahrq.gov/issue/err-human-patient-misinterpretations-prescription-drug-label-instructions
February 28, 2011 - Study
To err is human: patient misinterpretations of prescription drug label instructions.
Citation Text:
Wolf MS, Davis TC, Shrank WH, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67(3):293-300.
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psnet.ahrq.gov/issue/framework-classifying-factors-contribute-error-emergency-department
February 14, 2024 - Commentary
A framework for classifying factors that contribute to error in the emergency department.
Citation Text:
Cosby K. A framework for classifying factors that contribute to error in the emergency department. Ann Emerg Med. 2003;42(6):815-23.
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psnet.ahrq.gov/issue/mindless-mindful-practice-cognitive-bias-and-clinical-decision-making
November 23, 2016 - Commentary
From mindless to mindful practice—cognitive bias and clinical decision making.
Citation Text:
Croskerry P. From mindless to mindful practice--cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445-2448. doi:10.1056/NEJMp1303712.
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psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
November 02, 2022 - Newspaper/Magazine Article
Survey results from pharmacists provide support to enhance the organizational response to codes.
Citation Text:
Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
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psnet.ahrq.gov/issue/facilitating-patient-understanding-discharge-instructions-workshop-summary
October 08, 2014 - Meeting/Conference Proceedings
Facilitating Patient Understanding of Discharge Instructions: Workshop Summary.
Citation Text:
Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health a…
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psnet.ahrq.gov/issue/patient-safety-crossroads
March 18, 2019 - Commentary
Patient safety at the crossroads.
Citation Text:
Gandhi TK, Berwick DM, Shojania KG. Patient Safety at the Crossroads. JAMA. 2016;315(17):1829-30. doi:10.1001/jama.2016.1759.
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psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine
December 21, 2016 - Commentary
System-related and cognitive errors in laboratory medicine.
Citation Text:
Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191-196. doi:10.1515/dx-2018-0085.
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psnet.ahrq.gov/issue/learning-others-legal-aspects-sharing-patient-safety-data-using-provider-consortia
May 04, 2019 - Commentary
Learning from others: legal aspects of sharing patient safety data using provider consortia.
Citation Text:
Learning from others: legal aspects of sharing patient safety data using provider consortia. Liang BA; Weinger MB; Suydam S. J Patient Saf 2005;1:83–89
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psnet.ahrq.gov/issue/wise-event
October 09, 2024 - Commentary
Wise before the event.
Citation Text:
Watts G. Patient safety. Wise before the event. BMJ. 2010;340:c1378. doi:10.1136/bmj.c1378.
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psnet.ahrq.gov/issue/improving-safety-throughout-medication-use-process-neonatal-intensive-care-unit
January 27, 2012 - Commentary
Improving safety throughout the medication use process in a neonatal intensive care unit.
Citation Text:
Asdigha MN. Improving Safety Throughout the Medication Use Process in a Neonatal Intensive Care Unit. Hosp Pharm. 2010;41(11):1067-1075. doi:10.1310/hpj4111-1067.
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psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
July 27, 2016 - Newspaper/Magazine Article
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.
Citation Text:
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6. …
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psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
March 10, 2021 - Toolkit
Health IT Safe Practices for Closing the Loop.
Citation Text:
Health IT Safe Practices for Closing the Loop. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
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psnet.ahrq.gov/issue/systematic-review-medication-errors-pediatric-patients
March 05, 2010 - Review
Systematic review of medication errors in pediatric patients.
Citation Text:
Ghaleb M, Barber N, Franklin BD, et al. Systematic review of medication errors in pediatric patients. Ann Pharmacother. 2006;40(10):1766-76.
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psnet.ahrq.gov/issue/failure-weigh-patients-hospital-medication-safety-risk
April 22, 2015 - Study
Failure to weigh patients in hospital: a medication safety risk.
Citation Text:
Hilmer SN, Rangiah C, Bajorek B, et al. Failure to weigh patients in hospital: a medication safety risk. Intern Med J. 2007;37(9):647-50.
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psnet.ahrq.gov/issue/optimizing-crisis-resource-management-improve-patient-safety-and-team-performance-handbook
August 16, 2016 - Book/Report
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professionals.
Citation Text:
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professi…
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psnet.ahrq.gov/issue/speaking-about-patient-safety-requires-observant-questioner-and-high-index-suspicion
June 10, 2018 - Newspaper/Magazine Article
Speaking up about patient safety requires an observant questioner and a high index of suspicion.
Citation Text:
Speaking up about patient safety requires an observant questioner and a high index of suspicion. ISMP Medication Safety Alert! Acute Care Edition. Oc…
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - Book/Report
Classic
Serious Reportable Events in Healthcare—2011 Update.
Citation Text:
Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011.
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psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus
May 31, 2017 - Newspaper/Magazine Article
Death due to pharmacy compounding error reinforces need for safety focus.
Citation Text:
Death due to pharmacy compounding error reinforces need for safety focus. ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
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psnet.ahrq.gov/issue/implementing-systematic-response-medication-errors
August 27, 2009 - Commentary
Implementing a systematic response to medication errors.
Citation Text:
Larsen D, Cole R, Higton P. Implementing a systematic response to medication errors. Nurs Stand. 2007;21(48):35-40.
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