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psnet.ahrq.gov/node/42379/psn-pdf
August 08, 2013 - Prevalence and nature of adverse medical device events
in hospitalized children.
August 8, 2013
Brady PW, Varadarajan K, Peterson LE, et al. Prevalence and nature of adverse medical device events in
hospitalized children. J Hosp Med. 2013;8(7):390-3. doi:10.1002/jhm.2058.
https://psnet.ahrq.gov/issue/prevalence-an…
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psnet.ahrq.gov/node/74141/psn-pdf
December 01, 2021 - Incident reporting systems: what will it take to make them
less frustrating and achieve anything useful?
December 1, 2021
Shojania KG. Incident reporting systems: what will it take to make them less frustrating and achieve
anything useful? Jt Comm J Qual Patient Saf. 2021;47(12):755-758. doi:10.1016/j.jcjq.2021.10.…
-
psnet.ahrq.gov/node/38491/psn-pdf
January 31, 2011 - Diagnostic errors--The next frontier for patient safety.
January 31, 2011
Newman-Toker DE, Pronovost P. Diagnostic errors--the next frontier for patient safety. JAMA.
2009;301(10):1060-2. doi:10.1001/jama.2009.249.
https://psnet.ahrq.gov/issue/diagnostic-errors-next-frontier-patient-safety
Studies from autopsy dat…
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psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - Advancing perinatal patient safety through application of
safety science principles using health IT.
April 4, 2018
Webb J, Sorensen A, Sommerness SA, et al. Advancing perinatal patient safety through application of
safety science principles using health IT. BMC Med Inform Decis Mak. 2017;17(1):176.
doi:10.1186/s12…
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psnet.ahrq.gov/node/866279/psn-pdf
July 10, 2024 - Need to systematically identify and mitigate risks upon
hospitalisation for patients with chronic health
conditions.
July 10, 2024
Pronovost PJ, Carrington EM. Need to systematically identify and mitigate risks upon hospitalisation for
patients with chronic health conditions. BMJ Qual Saf. 2024;33(11):755-758. doi…
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psnet.ahrq.gov/node/853070/psn-pdf
August 30, 2023 - Activating pharmacists to reduce the frequency of
medication-related problems (ACTMed): a stepped wedge
cluster randomised trial.
August 30, 2023
Spinks J, Violette R, Boyle DIR, et al. Activating pharmacists to reduce the frequency of medication?related
problems (ACTMed): a stepped wedge cluster randomised trial.…
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psnet.ahrq.gov/node/37487/psn-pdf
May 26, 2011 - Predicting computerized physician order entry system
adoption in US hospitals: can the federal mandate be
met?
May 26, 2011
Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system
adoption in US hospitals: Can the federal mandate be met? Int J Med Inform. 2007;77(8).
doi:1…
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psnet.ahrq.gov/node/46690/psn-pdf
December 20, 2017 - Quality, safety, and outcomes in anaesthesia: what's to be
done? An international perspective.
December 20, 2017
Peden CJ, Campbell M, Aggarwal G. Quality, safety, and outcomes in anaesthesia: what's to be done? An
international perspective. Br J Anaesth. 2017;119. doi:10.1093/bja/aex346.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/841787/psn-pdf
December 21, 2022 - Electronic prescribing systems in hospitals to improve
medication safety: a multi-methods research programme.
December 21, 2022
Sheikh A, Coleman JJ, Chuter A, et al. Electronic prescribing systems in hospitals to improve medication
safety: a multimethods research programme. Programme Grants Appl Res. 2022;10(7):1-…
-
psnet.ahrq.gov/node/34103/psn-pdf
February 24, 2011 - Measuring errors and adverse events in health care.
February 24, 2011
Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med.
2003;18(1). doi:10.1046/j.1525-1497.2003.20147.x.
https://psnet.ahrq.gov/issue/measuring-errors-and-adverse-events-health-care
This article discusses t…
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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - Lost in translation: challenges and opportunities in
physician-to-physician communication during patient
handoffs.
August 5, 2009
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-
physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.
…
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psnet.ahrq.gov/node/47980/psn-pdf
May 01, 2019 - Intensive care medicine in 2050: preventing harm.
May 1, 2019
Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med.
2019;45(4):505-507. doi:10.1007/s00134-018-5353-z.
https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
This commentary discusses curren…
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psnet.ahrq.gov/node/838195/psn-pdf
September 28, 2022 - National Plan for Health Workforce Well-Being.
September 28, 2022
Dzau VJ, Kirch D, Murthy V, Nasca T, eds; NAM’s Action Collaborative on Clinician Well-Being and
Resilience. Washington DC: The National Academies Press; 2022. ISBN 9780309694674.
https://psnet.ahrq.gov/issue/national-plan-health-workforce-well-…
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psnet.ahrq.gov/node/867222/psn-pdf
December 04, 2024 - How many is too many? Using cognitive load theory to
determine the maximum safe number of inpatient
consultations for trainees.
December 4, 2024
Brondfield S, Blum AM, Mason JM, et al. How many is too many? Using cognitive load theory to determine
the maximum safe number of inpatient consultations for trainees. Ac…
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psnet.ahrq.gov/node/36102/psn-pdf
March 04, 2011 - Struggling to invent high-reliability organizations in
health care settings: insights from the field.
March 4, 2011
Dixon NM, Shofer M. Struggling to invent high-reliability organizations in health care settings: Insights from
the field. Health Serv Res. 2006;41(4 Pt 2):1618-32.
https://psnet.ahrq.gov/issue/strugg…
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psnet.ahrq.gov/node/46728/psn-pdf
March 27, 2018 - Near-miss event analysis enhances the barcode
medication administration process.
March 27, 2018
Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-
process
Near misses provide unique opportunities to ide…
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psnet.ahrq.gov/node/50376/psn-pdf
September 25, 2019 - Stakeholder perceptions of smart infusion pumps and
drug library updates: a multisite, interdisciplinary study.
September 25, 2019
DeLaurentis P, Walroth TA, Fritschle AC, et al. Stakeholder perceptions of smart infusion pumps and drug
library updates: A multisite, interdisciplinary study. Am J Health Syst Pharm. 2…
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psnet.ahrq.gov/node/47465/psn-pdf
October 17, 2018 - Mix-ups between epidural analgesia and IV antibiotics in
labor and delivery units continue to cause harm.
October 17, 2018
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
https://psnet.ahrq.gov/issue/mix-ups-between-epidural-analgesia-and-iv-antibiotics-labor-and-delivery-
units-continue-…
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psnet.ahrq.gov/node/73220/psn-pdf
May 05, 2021 - Identifying barriers to and opportunities for telehealth
implementation amidst the COVID-19 pandemic by using
a human factors approach: a leap into the future of health
care delivery?
May 5, 2021
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for telehealth implementation amidst
the COVID…
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psnet.ahrq.gov/node/840149/psn-pdf
November 16, 2022 - Developing strategic recommendations for implementing
smart pumps in advanced healthcare systems to improve
intravenous medication safety.
November 16, 2022
Sutherland A, Jones MD, Howlett M, et al. Developing strategic recommendations for implementing smart
pumps in advanced healthcare systems to improve intraven…