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psnet.ahrq.gov/node/40872/psn-pdf
January 23, 2012 - Hospital performance trends on national quality measures
and the association with Joint Commission accreditation.
January 23, 2012
Schmaltz SP, Williams SC, Chassin MR, et al. Hospital performance trends on national quality measures
and the association with joint commission accreditation. J Hosp Med. 2011;6(8). doi…
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psnet.ahrq.gov/node/42556/psn-pdf
August 28, 2013 - Findings and Lessons From the Improving Quality
Through Clinician Use of Health IT Grant Initiative.
August 28, 2013
Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF.
https://psnet.ahrq.gov/issue/findings-and-lessons-improving-quality-through-clinician-use-health-i…
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psnet.ahrq.gov/node/44784/psn-pdf
May 03, 2017 - WISH Patient Safety Forum
May 3, 2017
World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015.
https://psnet.ahrq.gov/issue/wish-patient-safety-forum
The 2015 conference focused on persisting barriers to patient safety worldwide and recommended
strategies to achieve lasting improvemen…
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psnet.ahrq.gov/node/45070/psn-pdf
October 03, 2017 - When There's Harm in the Hospital: Can Transparency
Replace "Deny and Defend"?
October 3, 2017
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend
This report provides the insight…
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psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/44380/psn-pdf
October 26, 2018 - From Safety-I to Safety-II: A White Paper.
October 26, 2018
Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper
To enhance patient safety, researchers must consider complexity in health care settings. This white pape…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/43456/psn-pdf
October 03, 2017 - Veterans' Access to Care through Choice, Accountability,
and Transparency Act of 2014.
October 3, 2017
HR 3230, 113th Congress: 2014.
https://psnet.ahrq.gov/issue/veterans-access-care-through-choice-accountability-and-transparency-act-
2014
The Veterans Affairs (VA) health system has both achieved success and str…
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psnet.ahrq.gov/node/43943/psn-pdf
December 04, 2015 - Culture Change in the NHS: Applying the Lessons of the
Francis Inquiries.
December 4, 2015
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries
The Francis inquiry uncovered numerous problems …
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psnet.ahrq.gov/node/36511/psn-pdf
January 07, 2011 - Facing ambiguous threats.
January 7, 2011
Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13,
157.
https://psnet.ahrq.gov/issue/facing-ambiguous-threats
This study describes how organizations respond to signs that may or may not portend future
catastrophes. The authors…
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psnet.ahrq.gov/node/46551/psn-pdf
October 25, 2017 - Inpatient notes: diagnostic excellence starts with an
incessant watch.
October 25, 2017
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch.
Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…
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psnet.ahrq.gov/node/43390/psn-pdf
July 30, 2014 - Hazards tied to medical records rush.
July 30, 2014
Rowland C.
https://psnet.ahrq.gov/issue/hazards-tied-medical-records-rush
Government incentives have led to rapid development and adoption of electronic health records (EHRs).
This newspaper article examines some of the unintended consequences of implementing ele…
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psnet.ahrq.gov/node/42303/psn-pdf
December 18, 2013 - A systematic review of strategies for reporting of neonatal
hospital–acquired bloodstream infections.
December 18, 2013
Folgori L, Bielicki J, Sharland M. A systematic review of strategies for reporting of neonatal hospital-
acquired bloodstream infections. Arch Dis Child Fetal Neonatal Ed. 2013;98(6):F518-23.
doi…
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psnet.ahrq.gov/node/45232/psn-pdf
August 10, 2016 - Promoting patient safety with perioperative hand-off
communication.
August 10, 2016
Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs.
2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144.
https://psnet.ahrq.gov/issue/promoting-patient-safety-perioperative-hand-commun…
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psnet.ahrq.gov/node/44123/psn-pdf
July 11, 2018 - The 2014 John M. Eisenberg Patient Safety and Quality
Awards.
July 11, 2018
Jt Comm J Qual Patient Saf. 2015;41(5):195-211.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/44032/psn-pdf
April 01, 2015 - ACOG Committee Opinion #621: patient safety and health
information technology.
April 1, 2015
Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health
information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44640/psn-pdf
February 20, 2016 - The problem with Plan-Do-Study-Act cycles.
February 20, 2016
Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52.
doi:10.1136/bmjqs-2015-005076.
https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles
Rapid-cycle improvement methods have been embraced as an approach t…
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psnet.ahrq.gov/node/45178/psn-pdf
December 04, 2016 - Do physicians clean their hands? Insights from a covert
observational study.
December 4, 2016
Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert
observational study. J Hosp Med. 2016;11(12):862-864. doi:10.1002/jhm.2632.
https://psnet.ahrq.gov/issue/do-physicians-c…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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psnet.ahrq.gov/node/44908/psn-pdf
June 07, 2016 - Speak up! Addressing the paradox plaguing patient-
centered care.
June 7, 2016
Mazor KM, Smith KM, Fisher K, et al. Speak Up! Addressing the Paradox Plaguing Patient-Centered Care.
Ann Intern Med. 2016;164(9):618-9. doi:10.7326/M15-2416.
https://psnet.ahrq.gov/issue/speak-addressing-paradox-plaguing-patient-center…