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psnet.ahrq.gov/node/39287/psn-pdf
February 10, 2010 - Office-based anesthesia.
February 10, 2010
Kurrek MM, Twersky RS. Office-based anesthesia. Can J Anaesth. 2010;57(3):256-72.
doi:10.1007/s12630-009-9238-z.
https://psnet.ahrq.gov/issue/office-based-anesthesia
This study reviews important issues and aspects of providing safe care in office-based anesthesia
practic…
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psnet.ahrq.gov/node/39137/psn-pdf
June 07, 2016 - The rise of patient safety organizations.
June 7, 2016
Ivill DS, Kearbey AH. New York Law J. November 2, 2009.
https://psnet.ahrq.gov/issue/rise-patient-safety-organizations
This news feature discusses legal aspects of Patient Safety Organizations' (PSO) role in data collection
and evaluation, work product designa…
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psnet.ahrq.gov/node/38336/psn-pdf
January 14, 2009 - Proceedings of a summit on preventing patient harm and
death from IV medication errors.
January 14, 2009
Proceedings of a summit on preventing patient harm and death from i.v. medication errors.
doi:10.2146/ajhp080406.
https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-…
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psnet.ahrq.gov/node/36600/psn-pdf
January 14, 2011 - Diagnostic pitfalls in paediatric ischaemic stroke.
January 14, 2011
Braun KPJ, Kappelle J, Kirkham FJ, et al. Diagnostic pitfalls in paediatric ischaemic stroke. Dev Med Child
Neurol. 2006;48(12):985-90.
https://psnet.ahrq.gov/issue/diagnostic-pitfalls-paediatric-ischaemic-stroke
The researchers analyzed case his…
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psnet.ahrq.gov/node/37971/psn-pdf
April 21, 2011 - Managing an acute adverse event in a radiology
department.
April 21, 2011
Kruskal JB, Siewert B, Anderson SW, et al. Managing an acute adverse event in a radiology department.
Radiographics. 2008;28(5):1237-50. doi:10.1148/rg.285085064.
https://psnet.ahrq.gov/issue/managing-acute-adverse-event-radiology-department…
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psnet.ahrq.gov/node/36113/psn-pdf
September 28, 2010 - "It's not our ass": medical resident sense-making
regarding lawsuits.
September 28, 2010
Noland CM, Carl WJ. "It's not our ass": medical resident sense-making regarding lawsuits. Health
Commun. 2006;20(1):81-9.
https://psnet.ahrq.gov/issue/its-not-our-ass-medical-resident-sense-making-regarding-lawsuits
The inves…
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psnet.ahrq.gov/node/35869/psn-pdf
July 23, 2010 - Five ways you can reduce inappropriate prescribing in the
elderly: a systematic review.
July 23, 2010
Garcia RM. Five ways you can reduce inappropriate prescribing in the elderly: a systematic review. J Fam
Pract. 2006;55(4):305-12.
https://psnet.ahrq.gov/issue/five-ways-you-can-reduce-inappropriate-prescribing-el…
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psnet.ahrq.gov/node/37070/psn-pdf
April 21, 2011 - Excessive work hours of physicians in training in El
Salvador: putting patients at risk.
April 21, 2011
Taylor KRF. Excessive work hours of physicians in training in El Salvador: putting patients at risk. PLoS
Med. 2007;4(7):e205.
https://psnet.ahrq.gov/issue/excessive-work-hours-physicians-training-el-salvador-pu…
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psnet.ahrq.gov/node/36594/psn-pdf
May 27, 2011 - Right tech dose helps medicine go down.
May 27, 2011
Patton S. CIO Magazine. July 12, 2006.
https://psnet.ahrq.gov/issue/right-tech-dose-helps-medicine-go-down
The author describes some common mistakes involving the design and launch of computerized physician
order entry (CPOE) initiatives and provides sugges…
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psnet.ahrq.gov/node/35058/psn-pdf
June 22, 2009 - Predicting and preventing adverse drug reactions in the
very old.
June 22, 2009
Merle L, Laroche M-L, Dantoine T, et al. Predicting and preventing adverse drug reactions in the very old.
Drugs Aging. 2005;22(5):375-92.
https://psnet.ahrq.gov/issue/predicting-and-preventing-adverse-drug-reactions-very-old
The auth…
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psnet.ahrq.gov/node/34940/psn-pdf
June 23, 2009 - Medication safety: look-alike/sound-alike drugs in home
care.
June 23, 2009
Friedman MMG. Medication safety: look-alike/sound-alike drugs in home care. Home Healthc Nurse.
2005;23(4):243-253.
https://psnet.ahrq.gov/issue/medication-safety-look-alikesound-alike-drugs-home-care
This article reviews the National Pat…
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psnet.ahrq.gov/node/36740/psn-pdf
July 26, 2011 - The problem of engaging hospital doctors in promoting
safety and quality in clinical care.
July 26, 2011
Neale G, Vincent CA, Darzi SA. The problem of engaging hospital doctors in promoting safety and quality
in clinical care. J R Soc Promot Health. 2007;127(2):87-94.
https://psnet.ahrq.gov/issue/problem-engaging-…
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psnet.ahrq.gov/node/34961/psn-pdf
June 22, 2009 - Improving hospital performance: culture change is not
the answer.
June 22, 2009
Leggat SG, Dwyer J. Improving hospital performance: culture change is not the answer. Healthc Q.
2005;8(2):60-6.
https://psnet.ahrq.gov/issue/improving-hospital-performance-culture-change-not-answer
The authors suggest that people man…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/node/35597/psn-pdf
June 21, 2010 - Prescription of teratogenic medications in United States
ambulatory practices.
June 21, 2010
Schwarz EB, Maselli J, Norton M, et al. Prescription of teratogenic medications in United States ambulatory
practices. Am J Med. 2005;118(11):1240-9.
https://psnet.ahrq.gov/issue/prescription-teratogenic-medications-united…
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psnet.ahrq.gov/node/43044/psn-pdf
March 19, 2014 - Improvement of Pennsylvania healthcare consumers'
awareness of patient safety.
March 19, 2014
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
https://psnet.ahrq.gov/issue/improvement-pennsylvania-healthcare-consumers-awareness-patient-safety
Patients are increasingly being asked to assume a role in ensurin…
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psnet.ahrq.gov/node/35250/psn-pdf
February 24, 2011 - The outcomes card: development of a systems-based
practice educational tool.
February 24, 2011
Tomolo A, Caron A, Perz ML, et al. The outcomes card. J Gen Intern Med. 2005;20(8). doi:10.1111/j.1525-
1497.2005.0168.x.
https://psnet.ahrq.gov/issue/outcomes-card-development-systems-based-practice-educational-tool
Th…
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psnet.ahrq.gov/node/39465/psn-pdf
May 08, 2018 - Latest heparin fatality speaks loudly—what have you
done to stop the bleeding?
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
Detailing a recent lethal overdose of heparin, this …
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psnet.ahrq.gov/node/35862/psn-pdf
November 18, 2016 - Medical gas containers and closures; current good
manufacturing practice requirements.
November 18, 2016
Fed Regist. 2016 Nov 18;81(223):81685-81697.
https://psnet.ahrq.gov/issue/medical-gas-containers-and-closures-current-good-manufacturing-practice-
requirements
This U.S. Food and Drug Administration (FDA)…
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psnet.ahrq.gov/node/37450/psn-pdf
June 13, 2011 - Technical patient safety solutions for medicines
reconciliation on admission of adults to hospital.
June 13, 2011
Manchester, UK: National Institute for Health and Clinical Excellence; 2015.
https://psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-
hospital
This gu…