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  1. psnet.ahrq.gov/issue/toward-improving-patient-safety-through-voluntary-peer-peer-assessment
    August 25, 2015 - Commentary Toward improving patient safety through voluntary peer-to-peer assessment. Citation Text: Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981. …
  2. psnet.ahrq.gov/issue/new-approach-assessing-patient-safety-aspects-routine-practice-using-example-doctors
    April 24, 2019 - Study A new approach of assessing patient safety aspects in routine practice using the example of "doctors handwritten prescriptions." Citation Text: Sendlhofer G, Pregartner G, Gombotz V, et al. A new approach of assessing patient safety aspects in routine practice using the example of …
  3. psnet.ahrq.gov/issue/use-standard-risk-screening-and-assessment-forms-prevent-harm-older-people-australian
    May 11, 2022 - Study Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study. Citation Text: Redley B, Raggatt M. Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mix…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49742/psn-pdf
    September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41003/psn-pdf
    April 16, 2018 - Gap assessment of hospitals' adoption of the just culture principles. April 16, 2018 Barger DM; Marella W; Charney FJ. https://psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles This article reports that Pennsylvania health care organizations overestimated their adoption of just culture…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47921/psn-pdf
    June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. June 18, 2019 Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006. https://psnet.ahrq.gov…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41315/psn-pdf
    October 10, 2012 - 2012 ISMP International Medication Safety Self Assessment for Oncology. October 10, 2012 Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada. https://psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology This tool evaluates the safety of canc…
  8. psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - In Conversation With… John D. Birkmeyer, MD May 1, 2015  Citation Text: In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Fo…
  9. psnet.ahrq.gov/issue/reducing-latent-errors-drift-errors-and-stakeholder-dissonance
    December 14, 2010 - Commentary Reducing latent errors, drift errors, and stakeholder dissonance. Citation Text: Reducing latent errors, drift errors, and stakeholder dissonance. Samaras GM. Work: J Prev Assess Rehabil. 2012;41:1948-1955. Copy Citation Save Save to your library …
  10. psnet.ahrq.gov/issue/secondary-traumatic-stress-ob-gyn-mixed-methods-analysis-assessing-physician-impact-and-needs
    July 07, 2021 - Study Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs. Citation Text: Kruper A, Domeyer-Klenske A, Treat R, et al. Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs. J Surg Educ. 2021;78…
  11. psnet.ahrq.gov/issue/assessing-content-validity-and-user-perspectives-team-check-tool-expert-survey-and-user-focus
    January 02, 2017 - Study Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups. Citation Text: Marsteller JA, Hsu Y-J, Chan KS, et al. Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups. B…
  12. psnet.ahrq.gov/issue/when-order-sets-do-not-align-clinician-workflow-assessing-practice-patterns-electronic-health
    March 24, 2019 - Study When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. Citation Text: Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Q…
  13. psnet.ahrq.gov/issue/do-we-know-what-foundation-year-doctors-think-about-patient-safety-incident-reporting
    April 12, 2017 - Study Do we know what foundation year doctors think about patient safety incident reporting? Development of a web based tool to assess attitude and knowledge. Citation Text: Robson J, de Wet C, McKay J, et al. Do we know what foundation year doctors think about patient safety incident …
  14. psnet.ahrq.gov/issue/simulation-debriefing-enhanced-needs-assessment-address-quality-markers-health-care
    June 22, 2022 - Study Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation for prospective hazard analysis. Citation Text: Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to address quality markers in hea…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853774/psn-pdf
    September 27, 2023 - Early in their development, triage assessments were limited in scope and intended to be completed within
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33722/psn-pdf
    December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011 In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and Executive Di…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38296/psn-pdf
    May 21, 2014 - Assessment of the AHRQ Patient Safety Initiative: Final Report Evaluation Report IV. May 21, 2014 Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2008. ISBN: 9780833044808 https://psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-final-report-evaluation-report-iv This re…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867805/psn-pdf
    February 26, 2025 - incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement Pressure injuries are better assessed, although those assessments
  19. psnet.ahrq.gov/issue/simple-strategies-avoid-medication-errors
    April 22, 2017 - Commentary Simple strategies to avoid medication errors. Citation Text: Jenkins RH, Vaida AJ. Simple strategies to avoid medication errors. Fam Pract Manag. 2007;14(2):41-47. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  20. psnet.ahrq.gov/issue/identity-crisis-examination-costs-and-benefits-unique-patient-identifier-us-health-care
    May 21, 2014 - Book/Report Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System. Citation Text: Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System. Hillestad R, Bigelow …

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