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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - With this as the goal, the suspected error should be reported to
organizational leadership and then analyzed
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - reviewed for appropriateness as well as the frequency of review.9 Override
reports should be routinely analyzed
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - Hospital data can be collected and analyzed and feedback on performance should be provided to individuals
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - overnight when nurse staffing and
monitoring decrease to encourage sleep
– In 42% of claims data analyzed
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - Community Behavioral Health – CCBHC; and Primary and Behavioral Health Care Integration-PBHCI), has analyzed
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - negatively associated with job strain. 4 Data collected from a disability healthcare organization were analyzed
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - medication errors that occur in acute care environments, serious ambulatory medication errors should also be analyzed
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - penicillin and cephalosporin use increased approximately twofold; moreover, among more than 1000 test doses analyzed
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/node/33688/psn-pdf
October 01, 2009 - In Conversation with... Charles Ornstein
October 1, 2009
In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-charles-ornstein
Editor's note: Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New
York. Formerly with th…
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - In Conversation With... Charles A Crecelius, MD, PhD,
CMD and Lori L Popejoy, PhD, RN, FAAN
October 28, 2020
In Conversation With.. Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-po…
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Implementation of Patient Safety Projects
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Organizational Learning
Curated Library
Foundations
Organizational learning: health care leaders need to design structures and processes that enhance
collective learning.
Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35.
This comment…
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - PowerPoint Presentation
Spotlight
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
1
This presentation is based on the June 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Reporting Patient Safety Events
Citation Text:
Reporting Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - We have analyzed all data for the last 15 years, and our major and minor
complication rate for all of