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psnet.ahrq.gov/node/40572/psn-pdf
June 27, 2018 - Understanding care transitions as a patient safety issue.
June 27, 2018
Butterfield S; Stegel C; Glock S; Tartaglia D.
https://psnet.ahrq.gov/issue/understanding-care-transitions-patient-safety-issue
This article describes a regional collaborative to enhance care transitions of Medicare beneficiaries by
improving …
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psnet.ahrq.gov/node/38187/psn-pdf
October 29, 2008 - The importance of simulation: preventing hand-off
mistakes.
October 29, 2008
Clancy CM. The importance of simulation: preventing hand-off mistakes. AORN J. 2008;88(4):625-627.
doi:10.1016/j.aorn.2008.09.007.
https://psnet.ahrq.gov/issue/importance-simulation-preventing-hand-mistakes
This article discusses an AHRQ…
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psnet.ahrq.gov/node/40261/psn-pdf
March 02, 2011 - Doctors' handovers in hospitals: a literature review.
March 2, 2011
Raduma-Tomàs MA, Flin R, Yule S, et al. Doctors' handovers in hospitals: a literature review. BMJ Qual
Saf. 2011;20(2):128-33. doi:10.1136/bmjqs.2009.034389.
https://psnet.ahrq.gov/issue/doctors-handovers-hospitals-literature-review
This review ex…
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psnet.ahrq.gov/node/38370/psn-pdf
August 22, 2009 - Monitoring for medication errors in outpatient settings.
August 22, 2009
Balkrishnan R, Foss CE, Pawaskar M, et al. Monitoring for medication errors in outpatient settings. J
Dermatolog Treat. 2009;20(4):229-32. doi:10.1080/09546630802607487.
https://psnet.ahrq.gov/issue/monitoring-medication-errors-outpatient-sett…
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www.ahrq.gov/patient-safety/reports/issue-briefs/healthit-ed-figure1.html
February 01, 2021 - Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments
Figure 1. Potential applications of health technology and patient engagement in the ED diagnostic process
Previous Page Next Page
Table of Contents
Health Information Technology for Engaging Pa…
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psnet.ahrq.gov/node/36597/psn-pdf
June 24, 2015 - Patient safety: learning from the aviation industry.
June 24, 2015
Kosnik LK, Brown J, Maund T. Patient safety: learning from the aviation industry. Nurs Manage.
2007;38(1):25-30; quiz 31.
https://psnet.ahrq.gov/issue/patient-safety-learning-aviation-industry
The authors explain the value of crew resource manageme…
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psnet.ahrq.gov/node/42756/psn-pdf
November 20, 2013 - Removing the "me" from "MD."
November 20, 2013
Parikh RB. Removing the “Me” From “MD”. JAMA. 2013;310(18). doi:10.1001/jama.2013.280722.
https://psnet.ahrq.gov/issue/removing-me-md
Recounting what one medical student learned by shadowing a nurse, this commentary emphasizes the
importance of interprofessional commu…
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psnet.ahrq.gov/node/36010/psn-pdf
January 02, 2017 - Operating room briefings: working on the same page.
January 2, 2017
Makary MA, Holzmueller CG, Thompson DA, et al. Operating room briefings: working on the same page. Jt
Comm J Qual Patient Saf. 2006;32(6):351-5.
https://psnet.ahrq.gov/issue/operating-room-briefings-working-same-page
The authors describe a tool fo…
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psnet.ahrq.gov/node/42112/psn-pdf
March 13, 2013 - Anger management courses are a new tool for dealing
with out-of-control doctors.
March 13, 2013
Boodman SG. Washington Post. March 4, 2013.
https://psnet.ahrq.gov/issue/anger-management-courses-are-new-tool-dealing-out-control-doctors
This newspaper article reports on how anger management courses can address phy…
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psnet.ahrq.gov/training-catalog/care-forum
July 07, 2025 - CARe Forum
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Organization:
Organization
Betsy Lehman Center for Patient Safety
Event Description: The annual CARe Forum is…
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www.ahrq.gov/nursing-home/resources/emotional-organizational-support.html
August 01, 2022 - Emotional and Organizational Support for Staff Learning Module Series
Resource: Emotional and Organizational Support for Staff Learning Module Series
This series of three learning modules features strategies to help nursing home teams recognize and manage stress, work together to tackle common challenges, a…
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psnet.ahrq.gov/node/41198/psn-pdf
March 07, 2012 - A handoff is not a telegram: an understanding of the
patient is co-constructed.
March 7, 2012
Cohen MD, Hilligoss B, Amaral ACK-B. A handoff is not a telegram: an understanding of the patient is co-
constructed. Crit Care. 2012;16(1):303. doi:10.1186/cc10536.
https://psnet.ahrq.gov/issue/handoff-not-telegram-under…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/proposed-changes-cahps-c&g-survey2015.pdf
March 01, 2015 - R: N/S/U/A
How Well Providers
Communicate with Patients
(6 items)
Revised communication
composite
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_508.docx
April 05, 2013 - significantly increases the likelihood of learning, innovation, and sustainability.3,4 Hospital leaders communicate
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
May 01, 2018 - Chartbook on Hispanic Health Care: Slide Presentation—Part 3
2014 National Healthcare Quality and Disparities Report
Trends in Access and Priorities of the National Quality Strategy
Slide 1
National Healthcare Quality and Disparities Report Chartbook on Health Care for Hispanics
Part 3: Trends in Acce…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/SOPS-Nursing-Home-DB-Part-I-2023.pdf
January 01, 2023 - Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2023 User Database Report Part I
SURVEYS ON PATIENT
SAFETY CULTURE
Nursing Home Survey:
2023 User Database Report
Surveys on
Patient Safety
Culture™
PATIENT
SAFETY
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Surveys on Patient Safety CultureTM (SOPS®)…
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psnet.ahrq.gov/node/42225/psn-pdf
April 24, 2013 - Brigham and Women's airing medical mistakes.
April 24, 2013
Kowalczyk L.
https://psnet.ahrq.gov/issue/brigham-and-womens-airing-medical-mistakes
This newspaper article describes how one hospital has fostered open communication about medical errors
through a monthly newsletter that recounts mistakes in an effort to…
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psnet.ahrq.gov/node/36955/psn-pdf
September 13, 2011 - Patient safety in after-hours telephone medicine.
September 13, 2011
Killip S, Ireson CL, Love MM, et al. Patient safety in after-hours telephone medicine. Fam Med.
2007;39(6):404-9.
https://psnet.ahrq.gov/issue/patient-safety-after-hours-telephone-medicine
The investigators talked with patients who had used a fam…
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psnet.ahrq.gov/node/37190/psn-pdf
October 07, 2011 - Medical errors arising from outsourcing laboratory and
radiology services.
October 7, 2011
Chasin BS, Elliott SP, Klotz SA. Medical errors arising from outsourcing laboratory and radiology services.
Am J Med. 2007;120(9):819.e9-11.
https://psnet.ahrq.gov/issue/medical-errors-arising-outsourcing-laboratory-and-radi…
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psnet.ahrq.gov/node/46852/psn-pdf
March 07, 2018 - NHS Resolution.
March 7, 2018
NHS Resolution.
https://psnet.ahrq.gov/issue/nhs-resolution
The National Health Service (NHS) is a global leader in patient safety improvement. This website
coalesces information and activities generated by three NHS improvement efforts: patient compensation,
performance assessment, …