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psnet.ahrq.gov/node/838637/psn-pdf
October 19, 2022 - Patient safety and legal regulations: a total-scale analysis
of the scientific literature.
October 19, 2022
Yeung AWK, Kletecka-Pulker M, Klager E, et al. Patient safety and legal regulations: a total-scale analysis
of the scientific literature. J Patient Saf. 2022;18(7):e1116-e1123. doi:10.1097/pts.000000000000104…
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psnet.ahrq.gov/node/60669/psn-pdf
July 08, 2020 - Participation in a system-thinking simulation experience
changes adverse event reporting.
July 8, 2020
Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event
reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473.
https://psnet.ahrq.gov/issue/parti…
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psnet.ahrq.gov/node/60949/psn-pdf
September 23, 2020 - Why accountability sharing in health care organizational
cultures means patients are probably safer.
September 23, 2020
Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.
https://psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-
patients-are-probably
The recognitio…
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psnet.ahrq.gov/node/39506/psn-pdf
March 23, 2011 - Readiness for organisational change among general
practice staff.
March 23, 2011
Christl B, Harris MF, Jayasinghe UW, et al. Readiness for organisational change among general practice
staff. Qual Saf Health Care. 2010;19(5):e12. doi:10.1136/qshc.2009.033373.
https://psnet.ahrq.gov/issue/readiness-organisational-ch…
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psnet.ahrq.gov/node/34733/psn-pdf
November 19, 2015 - Out of the Crisis.
November 19, 2015
Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering
Study, 1986. ISBN: 9780911379013.
https://psnet.ahrq.gov/issue/out-crisis
Deming believes that American companies need to transform their method of management to engage and
compete…
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psnet.ahrq.gov/node/42874/psn-pdf
January 29, 2014 - Interdisciplinary Perspectives on Medical Error.
January 29, 2014
J Public Health Res. 2013;2:e22-e33.
https://psnet.ahrq.gov/issue/interdisciplinary-perspectives-medical-error
This special issue explores the challenges of advancing patient safety and highlights the value of
interdisciplinary collaboration to achi…
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psnet.ahrq.gov/node/45414/psn-pdf
August 17, 2016 - The next wave of hospital innovation to make patients
safer.
August 17, 2016
Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ.
https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
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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/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/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/46306/psn-pdf
August 02, 2017 - Use of cascading A3s to drive systemwide improvement.
August 2, 2017
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt
Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
https://psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-impr…
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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/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/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/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/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/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/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
April 04, 2011 - Study
Classic
Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
Citation Text:
Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safet…
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psnet.ahrq.gov/issue/exploring-relationships-between-hospital-patient-safety-culture-and-consumer-reports-safety
July 21, 2016 - Study
Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.
Citation Text:
Smith SA, Yount N, Sorra J. Exploring relationships between hospital patient safety culture and Consumer Reports safety scores. BMC Health Serv Res. 2017;17(1):143. do…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - Spotlight
Spotlight
Out of Sight, Out of Mind: Out-of-Office Test Result Management
1
Source and Credits
This presentation is based on the May 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Eric Poon, MD, MPH, Duke University School o…