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psnet.ahrq.gov/issue/va-health-care-selected-credentialing-requirements-seven-medical-facilities-met-aspect
July 05, 2006 - Government Resource
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.
Citation Text:
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileg…
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psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-processes-responding-reported-adverse
August 15, 2012 - Book/Report
Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.
Citation Text:
Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events. Washington, DC: United States Government Acco…
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psnet.ahrq.gov/issue/va-health-care-steps-taken-improve-practitioner-screening-facility-compliance-screening
September 28, 2010 - Government Resource
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Citation Text:
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor. W…
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psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
January 29, 2015 - Commentary
Fostering transparency in outcomes, quality, safety, and costs.
Citation Text:
Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs. JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039.
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DOI …
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psnet.ahrq.gov/node/44322/psn-pdf
June 21, 2016 - Emotional harm from disrespect: the neglected
preventable harm.
June 21, 2016
Sokol-Hessner L, Folcarelli P, Sands KEF. Emotional harm from disrespect: the neglected preventable
harm. BMJ Qual Saf. 2015;24(9):550-3. doi:10.1136/bmjqs-2015-004034.
https://psnet.ahrq.gov/issue/emotional-harm-disrespect-neglected-pre…
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psnet.ahrq.gov/node/34690/psn-pdf
February 10, 2011 - Systems analysis of adverse drug events.
February 10, 2011
Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study
Group. JAMA. 1995;274(1):35-43.
https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
The authors report a "systems analysis" of the adverse drug…
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psnet.ahrq.gov/node/40805/psn-pdf
July 19, 2016 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2011.
July 19, 2016
Oakbrook Terrace, IL: The Joint Commission; September 2011.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2011
This report emphasizes perfor…
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psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lecture
November 02, 2014 - Commentary
New world of patient safety. 23rd Annual Samuel Jason Mixter Lecture.
Citation Text:
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg. 2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
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DOI Google Schola…
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psnet.ahrq.gov/node/42652/psn-pdf
October 31, 2014 - Safety in numbers: the development of Leapfrog's
composite patient safety score for US hospitals.
October 31, 2014
Austin M, D'Andrea G, Birkmeyer JD, et al. Safety in numbers: the development of Leapfrog's composite
patient safety score for U.S. hospitals. J Patient Saf. 2014;10(1):64-71.
doi:10.1097/PTS.0b013e31…
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psnet.ahrq.gov/node/44497/psn-pdf
September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in
Root Cause Analyses of Adverse Events.
September 9, 2015
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-
advers…
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psnet.ahrq.gov/node/39002/psn-pdf
January 03, 2017 - Engaging the patient as observer to promote hand
hygiene compliance in ambulatory care.
January 3, 2017
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in
ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25.
https://psnet.ahrq.gov/issue/engaging-patient-observ…
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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - Developing a reporting culture: learning from close calls
and hazardous conditions.
January 17, 2019
Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert.
2018;(60):1-8.
https://psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-…
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psnet.ahrq.gov/node/41610/psn-pdf
January 25, 2017 - Adverse events among children in Canadian hospitals:
the Canadian Paediatric Adverse Events Study.
January 25, 2017
Matlow A, Baker R, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian
Paediatric Adverse Events Study. CMAJ. 2012;184(13):E709-718. doi:10.1503/cmaj.112153.
https://…
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psnet.ahrq.gov/node/44694/psn-pdf
November 10, 2016 - America's Hospitals: Improving Quality and Safety—The
Joint Commission's Annual Report 2015.
November 10, 2016
Oakbrook Terrace, IL: The Joint Commission; November 2015.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2015
The annual report from The Jo…
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psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
June 01, 2016 - Commentary
"Never events" and the quest to reduce preventable harm.
Citation Text:
Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288.
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psnet.ahrq.gov/issue/identification-doctors-risk-recurrent-complaints-national-study-healthcare-complaints
September 07, 2011 - Study
Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.
Citation Text:
Bismark M, Spittal MJ, Gurrin LC, et al. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Aust…
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psnet.ahrq.gov/node/39721/psn-pdf
September 20, 2011 - Physicians' perceptions, preparedness for reporting, and
experiences related to impaired and incompetent
colleagues.
September 20, 2011
DesRoches CM, Rao SR, Fromson J, et al. Physicians' perceptions, preparedness for reporting, and
experiences related to impaired and incompetent colleagues. JAMA. 2010;304(2):187-…
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - Investigating the association of alerts from a national
mortality surveillance system with subsequent hospital
mortality in England: an interrupted time series analysis.
November 21, 2018
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national mortality
surveillance system with …
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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - Impact of inpatient harms on hospital finances and
patient clinical outcomes.
May 19, 2018
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J
Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.0000000000000171.
https://psnet.ahrq.gov/issue/impact-inpatient-harms…