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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - must not simply try to avoid the use of nonanalytic, pattern recognition decision-making but instead aim
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psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
May 01, 2023 - Toolkit
Opioid deprescribing toolkit.
Citation Text:
Health Innovation East, National Health Service. Opioid deprescribing toolkit.
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psnet.ahrq.gov/issue/making-dialysis-safer-patients-coalition
April 06, 2022 - Government Resource
Making Dialysis Safer for Patients Coalition.
Citation Text:
Making Dialysis Safer for Patients Coalition. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/node/41999/psn-pdf
January 01, 2016 - Maintaining and sustaining the On the CUSP: Stop BSI
model in Hawaii.
January 30, 2013
Lin D, Weeks K, Holzmueller CG, et al. Maintaining and Sustaining the On the CUSP: Stop BSI Model in
Hawaii. Jt Comm J Qual Patient Saf. 2016;39(2):51-60, AP3. doi:10.1016/s1553-7250(13)39008-4.
https://psnet.ahrq.gov/issue/main…
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psnet.ahrq.gov/node/35524/psn-pdf
October 06, 2016 - Does patient-centered design guarantee patient safety?:
Using human factors engineering to find a balance
between provider and patient needs.
October 6, 2016
France DJ, Throop P, Walczyk B, et al. Does Patient-Centered Design Guarantee Patient Safety? J Patient
Saf. 2008;1(3):145-153. doi:10.1097/01.jps.0000191550…
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psnet.ahrq.gov/node/38660/psn-pdf
November 13, 2009 - Improving medication error reporting in hospice care.
November 13, 2009
Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J
Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145.
https://psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-c…
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psnet.ahrq.gov/node/38175/psn-pdf
April 11, 2011 - An intervention to decrease narcotic-related adverse drug
events in children's hospitals.
April 11, 2011
Sharek PJ, McClead RE, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug
events in children's hospitals. Pediatrics. 2008;122(4):e861-e866. doi:10.1542/peds.2008-1011.
https://psnet.a…
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - Decreasing handoff-related care failures in children's
hospitals.
August 13, 2014
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's
hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844.
https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…
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psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - National Action Plan for Adverse Drug Event Prevention.
October 21, 2016
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health
and Human Services; September 2014.
https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
This national action pla…
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psnet.ahrq.gov/node/41942/psn-pdf
July 24, 2017 - Improving situation awareness to reduce unrecognized
clinical deterioration and serious safety events.
July 24, 2017
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical
deterioration and serious safety events. Pediatrics. 2013;131(1):e298-308. doi:10.1542/peds.2012-…
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psnet.ahrq.gov/node/42219/psn-pdf
July 22, 2013 - Parent perceptions of children's hospital safety climate.
July 22, 2013
Cox E, Carayon P, Hansen KW, et al. Parent perceptions of children's hospital safety climate. BMJ Qual
Saf. 2013;22(8):664-71. doi:10.1136/bmjqs-2012-001727.
https://psnet.ahrq.gov/issue/parent-perceptions-childrens-hospital-safety-climate
Pat…
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psnet.ahrq.gov/node/44965/psn-pdf
February 15, 2017 - Identification and Prioritization of Health IT Patient Safety
Measures.
February 15, 2017
Washington, DC: National Quality Forum; February 2016.
https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
Health information technology (IT) has transformed health care and improv…
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psnet.ahrq.gov/node/41777/psn-pdf
April 05, 2013 - Effect of nonpayment for preventable infections in U.S.
hospitals.
April 5, 2013
Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals.
N Engl J Med. 2012;367(15):1428-37. doi:10.1056/NEJMsa1202419.
https://psnet.ahrq.gov/issue/effect-nonpayment-preventable-infec…
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psnet.ahrq.gov/node/43101/psn-pdf
May 30, 2014 - Instituting a culture of professionalism: the establishment
of a Center for Professionalism and Peer Support.
May 30, 2014
Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for
professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
…
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psnet.ahrq.gov/node/42208/psn-pdf
April 17, 2013 - Hospital staff nurses' shift length associated with safety
and quality of care.
April 17, 2013
Stimpfel AW, Aiken LH. Hospital staff nurses' shift length associated with safety and quality of care. J Nurs
Care Qual. 2013;28(2):122-129. doi:10.1097/NCQ.0b013e3182725f09.
https://psnet.ahrq.gov/issue/hospital-staff-n…
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Preparing for Health Reform: The Federal Government
and the Nursing Workforce
September 1, 2012
Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
Per…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/node/50426/psn-pdf
January 01, 2020 - Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-
matched cohort study.
September 4, 2019
Lapointe-Shaw L, Bell CM, Austin PC, et al. Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-matched cohort s…
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psnet.ahrq.gov/node/38712/psn-pdf
June 17, 2009 - Silence, power and communication in the operating room.
June 17, 2009
Gardezi F, Lingard LA, Espin S, et al. Silence, power and communication in the operating room. J Adv
Nurs. 2009;65(7):1390-1399. doi:10.1111/j.1365-2648.2009.04994.x.
https://psnet.ahrq.gov/issue/silence-power-and-communication-operating-room
Co…
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psnet.ahrq.gov/node/42211/psn-pdf
April 24, 2013 - An organizational assessment of disruptive clinician
behavior: findings and implications.
April 24, 2013
Walrath JM, Dang D, Nyberg D. An Organizational Assessment of Disruptive Clinician Behavior. J Nurs
Care Qual. 2012;28(2):110-121. doi:10.1097/ncq.0b013e318270d2ba.
https://psnet.ahrq.gov/issue/organizational-a…