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psnet.ahrq.gov/node/35349/psn-pdf
November 18, 2011 - Leadership Guide to Patient Safety: Resources and Tools
for Establishing and Maintaining Patient Safety.
November 18, 2011
Botwinick L, Bisognano M, Haraden C. Cambridge, MA: Institute for Healthcare Improvement; 2006.
https://psnet.ahrq.gov/issue/leadership-guide-patient-safety-resources-and-tools-establishin…
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psnet.ahrq.gov/node/45005/psn-pdf
May 04, 2016 - Leading High-Reliability Organizations in Healthcare.
May 4, 2016
Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883.
https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare
High reliability has been recently adopted as a goal for health care. This book reviews the primar…
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psnet.ahrq.gov/node/34754/psn-pdf
February 06, 2018 - Patient Safety in Anesthetic Practice.
February 6, 2018
Morell RC; Eichhorn JH, eds. New York: Churchill Livingstone, 1997. ISBN: 9780443076824.
https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice
Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the
converge…
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psnet.ahrq.gov/node/45093/psn-pdf
September 04, 2016 - Radically redesigning patient safety.
September 4, 2016
Radick LE. Radically Redesigning Patient Safety. Healthcare executive. 2016;31(2):32-4, 36-40, 42.
https://psnet.ahrq.gov/issue/radically-redesigning-patient-safety
Leadership and staff commitment are required to achieve improvements in patient safety. Discuss…
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psnet.ahrq.gov/node/46117/psn-pdf
May 10, 2017 - Deep learning is a black box, but health care won't mind.
May 10, 2017
Brouillette M. MIT Technol Rev. April 27, 2017.
https://psnet.ahrq.gov/issue/deep-learning-black-box-health-care-wont-mind
Artificial intelligence can support diagnostic decision-making. This magazine article reports on the use of
algorithms to…
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psnet.ahrq.gov/node/40998/psn-pdf
December 14, 2011 - Identifying unintended consequences of quality
indicators: a qualitative study.
December 14, 2011
Lester HE, Hannon KL, Campbell S. Identifying unintended consequences of quality indicators: a
qualitative study. BMJ Qual Saf. 2011;20(12):1057-61. doi:10.1136/bmjqs.2010.048371.
https://psnet.ahrq.gov/issue/identify…
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psnet.ahrq.gov/node/37253/psn-pdf
January 10, 2017 - American Hospital Association-McKesson Quest for
Quality Prize.
January 10, 2017
Jt Comm J Qual Patient Saf. 2007;33(10):592-604.
https://psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize-0
This issue includes articles highlighting the achievements of the 2007 AHA McKesson Quest …
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psnet.ahrq.gov/node/34051/psn-pdf
March 07, 2005 - A call to excellence.
March 7, 2005
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
https://psnet.ahrq.gov/issue/call-excellence
This commentary, written by leadership from the Agency for Healthcare and Research Quality (AHRQ) and
the Centers for Medicare and Medicaid Services (…
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psnet.ahrq.gov/node/37588/psn-pdf
February 15, 2011 - Antibiotic timing and errors in diagnosing pneumonia.
February 15, 2011
Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med.
2008;168(4):351-6. doi:10.1001/archinternmed.2007.84.
https://psnet.ahrq.gov/issue/antibiotic-timing-and-errors-diagnosing-pneumonia
This stu…
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psnet.ahrq.gov/issue/patient-safety-climate-strength-concept-requires-more-attention
March 04, 2011 - Study
Patient safety climate strength: a concept that requires more attention.
Citation Text:
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
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Format:
…
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psnet.ahrq.gov/issue/program-prevent-catheter-associated-urinary-tract-infection-acute-care
December 21, 2017 - Study
Classic
A program to prevent catheter-associated urinary tract infection in acute care.
Citation Text:
Saint S, Greene T, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. New Engl J Med. 2016;374(22):2111-211…
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psnet.ahrq.gov/node/45590/psn-pdf
August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017.
August 2, 2017
Washington, DC: National Quality Forum; October 2016.
https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017
The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable
diagnosis. This we…
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psnet.ahrq.gov/node/42988/psn-pdf
March 05, 2014 - Between surveillance and subjectification: professionals
and the governance of quality and patient safety in
English hospitals.
March 5, 2014
Martin G, Leslie M, Minion J, et al. Between surveillance and subjectification: professionals and the
governance of quality and patient safety in English hospitals. Soc Sci …
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psnet.ahrq.gov/node/45169/psn-pdf
June 08, 2016 - High Reliability in Health Care.
June 8, 2016
Joint Commission Center for Transforming Healthcare.
https://psnet.ahrq.gov/issue/high-reliability-health-care
Development of high reliability remains an elusive goal for health care organizations. The Joint Commission
has also advocated for achieving high reliability …
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psnet.ahrq.gov/node/37261/psn-pdf
December 19, 2011 - Creating complex health improvement programs as
mindful organizations: from theory to action.
December 19, 2011
Issel M, Narasimha KM. Creating complex health improvement programs as mindful organizations: from
theory to action. J Health Organ Manag. 2007;21(2):166-83.
https://psnet.ahrq.gov/issue/creating-complex…
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psnet.ahrq.gov/node/39085/psn-pdf
November 11, 2009 - Integrating ethics and patient safety: the role of clinical
ethics consultants in quality improvement.
November 11, 2009
Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics
consultants in quality improvement. J Clin Ethics. 2009;20(3):220-6.
https://psnet.ah…
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psnet.ahrq.gov/node/42525/psn-pdf
November 20, 2013 - A Promise to Learn—a Commitment to Act: Improving the
Safety of Patients in England.
November 20, 2013
National Advisory Group on the Safety of Patients in England. London, England: Crown Publishing; August
2013.
https://psnet.ahrq.gov/issue/promise-learn-commitment-act-improving-safety-patients-england
An intern…
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psnet.ahrq.gov/node/34071/psn-pdf
February 18, 2011 - A middle ground on public accountability.
February 18, 2011
Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med.
2004;350(23):2409-2412.
https://psnet.ahrq.gov/issue/middle-ground-public-accountability
This commentary discusses the complex interplay between payers, purchasers, pati…
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psnet.ahrq.gov/node/41134/psn-pdf
July 06, 2012 - Differential impact of a crew resource management
program according to professional specialty.
July 6, 2012
Suva D, Haller G, Lübbeke A, et al. Differential impact of a crew resource management program according
to professional specialty. Am J Med Qual. 2012;27(4):313-20. doi:10.1177/1062860611423805.
https://psne…
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psnet.ahrq.gov/node/43912/psn-pdf
February 25, 2015 - Patient Safety in Dialysis Access.
February 25, 2015
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
https://psnet.ahrq.gov/issue/patient-safety-dialysis-access
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This
publication raises awa…