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psnet.ahrq.gov/node/73894/psn-pdf
February 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings
of a Workshop—in Brief.
February 22, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National
Academies Press; 2022.
https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis
Diagnostic errors remain an o…
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psnet.ahrq.gov/node/74064/psn-pdf
May 27, 2021 - Achieving zero inequity: lessons learned from patient
safety.
May 27, 2021
Gandhi TK. NEJM Catalyst. May 27, 2021.
https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety
The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system.
The author…
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psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
September 19, 2018 - Book/Report
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Citation Text:
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of M…
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psnet.ahrq.gov/issue/achieving-quality-improvement-nursing-home-influence-nursing-leadership-communication-and
September 04, 2010 - Study
Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.
Citation Text:
Vogelsmeier A, Scott-Cawiezell J. Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork. J N…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case June 2005
Getting to the Root of the Matter
Source and Credits
This presentation is based on the June 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Scott Flanders, MD; Sa…
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
November 1, 2018
Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
Perspective
In this month's PSNet perspective, I interview Dr. David M…
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - Back to Basics
March 1, 2007
Hellman R. Back to Basics. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/back-basics
The Case
A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with
right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/node/40082/psn-pdf
December 15, 2010 - Achieving Strong Teamwork Practices in Hospital Labor
and Delivery Units.
December 15, 2010
Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN:
9780833050557.
https://psnet.ahrq.gov/issue/achieving-strong-teamwork-practices-hospital-labor-and-delivery-units
This report …
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psnet.ahrq.gov/node/40317/psn-pdf
November 21, 2016 - Achieving an Exceptional Patient and Family Experience
of Inpatient Hospital Care.
November 21, 2016
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
https://psnet.ahrq.gov/issue/achieving-exceptional-patient-and-family-experience-inpatient-hospital-care
This whit…
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psnet.ahrq.gov/node/42186/psn-pdf
April 24, 2013 - High reliability: truly achieving healthcare quality and
safety.
April 24, 2013
Kaplan GS. Pursuing the perfect patient experience. Front Health Serv Manage. 2013;29(3):16-27.
https://psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
This commentary discusses how high reliability …
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psnet.ahrq.gov/node/43880/psn-pdf
February 04, 2015 - Healthcare Safety for Nursing Personnel: An
Organizational Guide to Achieving Results.
February 4, 2015
Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277.
https://psnet.ahrq.gov/issue/healthcare-safety-nursing-personnel-organizational-guide-achieving-results
This publication provides information abou…
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psnet.ahrq.gov/node/35595/psn-pdf
January 04, 2009 - Patient Safety: Achieving a New Standard of Care.
January 4, 2009
Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM,
Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa…
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psnet.ahrq.gov/node/35083/psn-pdf
March 29, 2007 - Patient Safety: Achieving a New Standard for Care.
March 29, 2007
Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC:
National Academies Press; 2004. ISBN 0309090776.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
This report details findings…