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psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
March 15, 2022 - Newspaper/Magazine Article
Do not let "Depo-" medications be a depot for mistakes.
Citation Text:
Do not let "Depo-" medications be a depot for mistakes. ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med.
2003;348:851-855.
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psnet.ahrq.gov/issue/five-rights-destination-without-map
September 14, 2016 - Newspaper/Magazine Article
The five rights: a destination without a map.
Citation Text:
The five rights: a destination without a map. ISMP Medication Safety Alert! Acute care edition. January 25, 2007.
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psnet.ahrq.gov/issue/mislabeling-event-batched-drugs-unintended-consequences-practice-changes
May 07, 2014 - Newspaper/Magazine Article
A mislabeling event with batched drugs: the unintended consequences of practice changes.
Citation Text:
A mislabeling event with batched drugs: the unintended consequences of practice changes. ISMP Medication Safety Alert! Acute Care Edition. 2014;19:1-3.&nbs…
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psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-report
November 02, 2016 - Book/Report
Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.
Citation Text:
Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report. Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
…
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psnet.ahrq.gov/node/43688/psn-pdf
November 30, 2016 - AHRQ Nursing Home Survey on Patient Safety Culture:
2014 User Comparative Database Report.
November 30, 2016
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research
and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
https://psnet.ahrq.gov/issue/ahrq-nursing-hom…
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psnet.ahrq.gov/issue/recurring-call-action-every-healthcare-organization-needs-medication-safety-officer
March 03, 2021 - Newspaper/Magazine Article
A recurring call to action: every healthcare organization needs a medication safety officer!
Citation Text:
A recurring call to action: every healthcare organization needs a medication safety officer! ISMP Medication Safety Alert! Acute care edition. February…
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psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - One systematic review identified 43
articles that included 6 tested interventions and 37 suggestions
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - kits may have valuable ideas for improving accuracy and efficiency and should be engaged regularly for suggestions
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Timely diagnosis of esophageal perforation
February 26, 2020
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
The Case
A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
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psnet.ahrq.gov/issue/safety-improvements-urged-mri-facilities
February 02, 2011 - Newspaper/Magazine Article
Safety improvements urged for MRI facilities.
Citation Text:
Mitka M. Safety improvements urged for MRI facilities. JAMA. 2005;294(17):2145-8.
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psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005)
September 1, 2005
View more articles from the same authors.
Citation Text:
Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…
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psnet.ahrq.gov/issue/evidence-anchoring-bias-during-physician-decision-making
November 17, 2021 - Study
Evidence for anchoring bias during physician decision-making.
Citation Text:
Ly DP, Shekelle PG, Song Z. Evidence for anchoring bias during physician decision-making. JAMA Intern Med. 2023;183(8):818-823. doi:10.1001/jamainternmed.2023.2366.
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psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
September 23, 2020 - Study
Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.
Citation Text:
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1…
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psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room
July 25, 2012 - Study
Classic
A prospective study of patient safety in the operating room.
Citation Text:
Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - attention to something of greater importance and away
from something that is less important.(16) Recent suggestions
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - "(13) The suggestions offered here have potential for physicians, and their staffs and
patients, to
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psnet.ahrq.gov/issue/follow-ismp-guidelines-safeguard-design-and-use-automated-dispensing-cabinets-adcs
May 07, 2018 - Newspaper/Magazine Article
Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).
Citation Text:
Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs). ISMP Medication Safety Alert! Acute Care Edition. Febr…