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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - A Little Shuteye
July 1, 2003
Farion KJ. A Little Shuteye. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/little-shuteye
The Case
A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The
pediatrician had heard of the availability of topical skin adhesive that can be…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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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…
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psnet.ahrq.gov/node/44003/psn-pdf
June 17, 2015 - Effects of patient safety culture interventions on incident
reporting in general practice: a cluster randomised trial.
June 17, 2015
Verbakel NJ, Langelaan M, Verheij TJM, et al. Effects of patient safety culture interventions on incident
reporting in general practice: a cluster randomised trial. Br J Gen Pract. 20…
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psnet.ahrq.gov/node/47038/psn-pdf
July 18, 2018 - Delivering Quality Health Services: A Global Imperative
for Universal Health Coverage.
July 18, 2018
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
https://psnet.ahrq.gov/issue/delivering-quality-health-services-global-imperative-universal-health-coverage
The Crossing the Quality C…
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psnet.ahrq.gov/node/47165/psn-pdf
June 13, 2018 - Changing how we think about healthcare improvement.
June 13, 2018
Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014.
doi:10.1136/bmj.k2014.
https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement
In learning organizations, leadership behavior creates a s…
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psnet.ahrq.gov/node/43647/psn-pdf
November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report.
November 12, 2014
Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.
https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…