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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/periodic-issue/periodic-issue-457
September 25, 2024 - An important aim was to improve teamwork and assertive communication between operating room (OR) team … An important aim was to improve teamwork and assertive communication between operating room (OR) team
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psnet.ahrq.gov/issue/safer-healthcare-strategies-real-world
March 23, 2022 - Book/Report
Classic
Safer Healthcare: Strategies for the Real World.
Citation Text:
Safer Healthcare: Strategies for the Real World. Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - For example, if a patient receives the correct medications for a particular condition (effectiveness aim … met), but they stop taking the medications because of side effects (patient-centered aim not met), their … health may then be negatively affected (safety aim not met). … Aims of Quality Healthcare Ultimate Potential Implications for Patient Safety if Quality Healthcare Aim
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - The aim was hospital safety. … we do in our daily work that would turn energy and
commitment and resources to achieving the 40/20 aim … can
align 10 or 20 levers like that over the same period of time in terms of going toward a common aim
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psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
June 29, 2022 - Study
Medication errors in community pharmacies: evaluation of a standardized safety program.
Citation Text:
Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218. doi:10.1016…
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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - make some progress in that area, our mission has expanded from safety in health care to the Triple Aim … The Triple Aim emerged from looking at problems in a new way. … One is the Triple Aim: IHI's vision that all of us in health care need to move from focus on the experience
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psnet.ahrq.gov/node/50897/psn-pdf
February 12, 2020 - Improving Safety and Security for Veterans Act of 2020.
February 12, 2020
HB 5616, 116th Congress: 2020.
https://psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020
This legislation aims to strengthen the US Veterans Health System by requiring reports on the quality of
care and patient safety…
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psnet.ahrq.gov/training-catalog/safer-care-save-lives-scsl
April 20, 2025 - Safer Care to Save Lives (SCSL)
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Organization:
Organization
European Society of Anaesthesiology and Intensive Care (ESAIC)
…
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psnet.ahrq.gov/issue/patient-complaints-healthcare-systems-systematic-review-and-coding-taxonomy
November 29, 2023 - Review
Patient complaints in healthcare systems: a systematic review and coding taxonomy.
Citation Text:
Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678-689. doi:10.1136/bmjqs-2013-002437. …
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psnet.ahrq.gov/issue/enhancing-safe-medication-use-home-care-insights-informal-caregivers
December 02, 2020 - Study
Enhancing safe medication use in home care: insights from informal caregivers.
Citation Text:
Gil-Hernández E, Ballester P, Guilabert M, et al. Enhancing safe medication use in home care: insights from informal caregivers. Front Med (Lausanne). 2024;11:1494771. doi:10.3389/fmed.202…
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psnet.ahrq.gov/issue/improving-hand-hygiene-eight-hospitals-united-states-targeting-specific-causes-noncompliance
April 13, 2022 - Study
Classic
Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.
Citation Text:
Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes …
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psnet.ahrq.gov/issue/missed-nursing-care-surgical-care-hazard-patient-safety-quantitative-study-within-incharge
July 12, 2023 - Study
Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme.
Citation Text:
Edfeldt K, Nyholm L, Jangland E, et al. Missed nursing care in surgical care– a hazard to patient safety: a quantitative study within the inCHARGE pr…
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psnet.ahrq.gov/node/50388/psn-pdf
September 25, 2019 - Patient Safety.
September 25, 2019
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
https://psnet.ahrq.gov/issue/patient-safety-17
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and
application-focused commentary. Their publishing output aims to gen…
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - Military Medicine 184,:114, 2019
Aim to contact your Battle
Buddy 2-3 times per week or
more (daily
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psnet.ahrq.gov/issue/hybrid-methodology-modeling-risk-adverse-events-complex-health-care-settings
November 11, 2015 - Study
A hybrid methodology for modeling risk of adverse events in complex health-care settings.
Citation Text:
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
…
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psnet.ahrq.gov/issue/crisis-management-during-anaesthesia-development-anaesthetic-crisis-management-manual
June 23, 2015 - Commentary
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.
Citation Text:
Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. …
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psnet.ahrq.gov/node/39092/psn-pdf
November 11, 2009 - Empowered Patient Coalition.
November 11, 2009
Email: info@EmpoweredPatientCoalition.org.
https://psnet.ahrq.gov/issue/empowered-patient-coalition
This group aims to engage the public in health care improvement efforts and personal patient support
through education, information, and toolkit dissemination. The Web …
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psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - Implement strategies to prevent persistent medication
errors and hazards: 2024.
April 3, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack of p…