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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/46094/psn-pdf
July 11, 2017 - Hiding in plain sight—resurrecting the power of
inspecting the patient.
July 11, 2017
Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA
Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634.
https://psnet.ahrq.gov/issue/hiding-plain-sight-resur…
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psnet.ahrq.gov/node/47799/psn-pdf
March 20, 2019 - Deep Medicine: How Artificial Intelligence Can Make
Healthcare Human Again.
March 20, 2019
Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632.
https://psnet.ahrq.gov/issue/deep-medicine-how-artificial-intelligence-can-make-healthcare-human-again
This book explores how advancements in technology can impr…
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psnet.ahrq.gov/node/47507/psn-pdf
December 21, 2018 - The fate of medicine in the time of AI.
December 21, 2018
Coiera E. The fate of medicine in the time of AI. Lancet. 2018;392(10162):2331-2332. doi:10.1016/S0140-
6736(18)31925-1.
https://psnet.ahrq.gov/issue/fate-medicine-time-ai
Artificial intelligence can improve practice by making synthesized data available in …
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psnet.ahrq.gov/node/45766/psn-pdf
February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based
Practices to Optimize Prescriber Use.
February 8, 2017
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy
and Management at Brandeis University; 2016.
https://psnet.ahrq.gov/issue/prescription-drug-monit…
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psnet.ahrq.gov/node/47423/psn-pdf
January 27, 2019 - A health system–wide initiative to decrease opioid-related
morbidity and mortality.
January 27, 2019
Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related
Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003.
https://psnet.…
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psnet.ahrq.gov/node/47713/psn-pdf
June 14, 2019 - Medication appropriateness in vulnerable older adults:
healthy skepticism of appropriate polypharmacy.
June 14, 2019
Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of
Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. doi:10.1111/jgs.15798.
https://psne…
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psnet.ahrq.gov/node/46079/psn-pdf
June 28, 2017 - Death due to pharmacy compounding error reinforces
need for safety focus.
June 28, 2017
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus
Compounding pharmacies prepare medicines for patients that a…
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psnet.ahrq.gov/node/43175/psn-pdf
December 12, 2014 - Interventions to improve safe and effective medicines use
by consumers: an overview of systematic reviews.
December 12, 2014
Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by
consumers: an overview of systematic reviews. Cochrane Database Syst Rev. 2014;(4):CD007768.
d…
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psnet.ahrq.gov/node/35850/psn-pdf
May 27, 2011 - Computerization can create safety hazards: a bar-coding
near miss.
May 27, 2011
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med.
2006;144(7):510-6.
https://psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss
This case study shares the …
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psnet.ahrq.gov/node/844774/psn-pdf
September 11, 2019 - Advances in Human Factors and Ergonomics in
Healthcare and Medical Devices.
September 11, 2019
Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501.
https://psnet.ahrq.gov/issue/advances-human-factors-and-ergonomics-healthcare-and-medical-devices
Human-centered processes, techno…
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psnet.ahrq.gov/node/853610/psn-pdf
September 20, 2023 - Ten years later, alarm fatigue is still a safety concern.
September 20, 2023
Albanowski K, Burdick KJ, Bonafide CP, et al. Ten years later, alarm fatigue is still a safety concern. AACN
Adv Crit Care. 2023;34(3):189-197. doi:10.4037/aacnacc2023662.
https://psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-sa…
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psnet.ahrq.gov/node/866698/psn-pdf
September 11, 2024 - Can we ensure medication safety with the use of speech
recognition software?
September 11, 2024
Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety
Alert! Acute Care. August 22, 2024;29(17):1-3.
https://psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-…
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psnet.ahrq.gov/node/72604/psn-pdf
December 23, 2020 - Organizational characteristics and perceptions of clinical
event notification services in healthcare settings: a study
of health information exchange.
December 23, 2020
Wiley KK, Hilts KE, Ancker JS, et al. Organizational characteristics and perceptions of clinical event
notification services in healthcare setting…
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psnet.ahrq.gov/node/46669/psn-pdf
January 17, 2018 - Effect of therapeutic interchange on medication
reconciliation during hospitalization and upon discharge
in a geriatric population.
January 17, 2018
Wang JS, Fogerty RL, Horwitz LI. Effect of therapeutic interchange on medication reconciliation during
hospitalization and upon discharge in a geriatric population. P…
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psnet.ahrq.gov/node/44981/psn-pdf
June 07, 2016 - Simulation-based training: the missing link to lastingly
improved patient safety and health?
June 7, 2016
Mileder LP, Schmölzer GM. Simulation-based training: the missing link to lastingly improved patient safety
and health? Postgrad Med J. 2016;92(1088):309-11. doi:10.1136/postgradmedj-2015-133732.
https://psnet.…
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psnet.ahrq.gov/node/47227/psn-pdf
October 03, 2018 - Clinical and financial effects of smart pump-electronic
medical record interoperability at a hospital in a regional
health system.
October 3, 2018
Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability
at a hospital in a regional health system. Am J Health Sy…
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psnet.ahrq.gov/node/846764/psn-pdf
March 29, 2023 - Senators threaten consequences after VA confirms 4
deaths tied to computer system tested in Spokane.
March 29, 2023
Donovan-Smith O. Spokesman Review. March 15, 2023.
https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-
system-tested-spokane
Implementations of elec…
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psnet.ahrq.gov/node/72832/psn-pdf
March 10, 2021 - Communication and Transparency as a Means to
Strengthening Workplace Culture During COVID-19.
March 10, 2021
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To
Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021.
doi:10.31478/202103a.
https:/…
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psnet.ahrq.gov/node/60233/psn-pdf
April 15, 2020 - Identifying safety hazards associated with intravenous
vancomycin through the analysis of patient safety event
reports.
April 15, 2020
Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin
through the analysis of patient safety event reports. Patient Safety. 2020;2…