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psnet.ahrq.gov/node/36204/psn-pdf
September 30, 2010 - Automated medication error studies with audit
supplementation were effectively designed and analyzed
by time series.
September 30, 2010
Shuster JJ, Winterstein AG. Automated medication error studies with audit supplementation were
effectively designed and analyzed by time series. J Clin Epidemiol. 2006;59(9).
doi…
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psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
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psnet.ahrq.gov/node/35111/psn-pdf
April 06, 2011 - Patient safety features of clinical computer systems:
questionnaire survey of GP views.
April 6, 2011
Morris CJ, Savelyich BSP, Avery A, et al. Patient safety features of clinical computer systems:
questionnaire survey of GP views. Qual Saf Health Care. 2005;14(3):164-8.
https://psnet.ahrq.gov/issue/patient-safety…
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psnet.ahrq.gov/node/37086/psn-pdf
October 03, 2011 - Failure mode and effects analysis: a useful tool for risk
identification and injury prevention.
October 3, 2011
Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…
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psnet.ahrq.gov/node/36622/psn-pdf
January 14, 2011 - Measuring errors in surgical pathology in real-life
practice: defining what does and does not matter.
January 14, 2011
Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does
and does not matter. Am J Clin Pathol. 2007;127(1):144-52.
https://psnet.ahrq.gov/issue/measu…
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psnet.ahrq.gov/node/37858/psn-pdf
June 25, 2008 - Measuring team performance in healthcare: review of
research and implications for patient safety.
June 25, 2008
Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and
implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.1016/j.jcrc.2007.12.005.
https://psnet.…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/73451/psn-pdf
June 30, 2021 - National Patient Safety Syllabus.
June 30, 2021
Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021.
https://psnet.ahrq.gov/issue/national-patient-safety-syllabus
Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a
challenge. This st…
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psnet.ahrq.gov/node/34618/psn-pdf
July 28, 2013 - National Survey on Consumers' Experiences With Patient
Safety and Quality Information.
July 28, 2013
Washington DC: Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School
of Public Health; 2004.
https://psnet.ahrq.gov/issue/national-survey-consumers-experiences-patient-safety-and-qual…
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psnet.ahrq.gov/node/41297/psn-pdf
September 19, 2012 - Failure mode and effects analysis: too little for too much?
September 19, 2012
Franklin BD, Shebl NA, Barber N. Failure mode and effects analysis: too little for too much? BMJ Qual Saf.
2012;21(7):607-11. doi:10.1136/bmjqs-2011-000723.
https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-mu…
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psnet.ahrq.gov/node/38785/psn-pdf
September 02, 2009 - An ethnographic study of classifying and accounting for
risk at the sharp end of medical wards.
September 2, 2009
Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk
at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362-9. doi:10.1016/j.socscimed.2009.…
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psnet.ahrq.gov/node/38117/psn-pdf
September 29, 2017 - Advances in Patient Safety: New Directions and
Alternative Approaches.
September 29, 2017
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-
4).
https://psnet.ahrq.gov/issue/advances-patient-safety-new-directions-and-alternative-approaches
The 115 articles freel…
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psnet.ahrq.gov/node/43718/psn-pdf
December 03, 2014 - Patient safety culture in nephrology nurse practice
settings: initial findings.
December 3, 2014
Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.
https://psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
This study utilized AHRQ patient safety culture surveys to asse…
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psnet.ahrq.gov/node/36221/psn-pdf
October 20, 2010 - Enhancing patient safety during hand-offs: standardized
communication and teamwork using the 'SBAR' method.
October 20, 2010
Hohenhaus S, Powell S, Hohenhaus JT. Am J Nurs. 2006;106(8):72A-72B.
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-
teamwork-using-sba…
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Ci…
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
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