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psnet.ahrq.gov/node/40592/psn-pdf
July 06, 2011 - Intrahospital transport to the radiology department: risk
for adverse events, nursing surveillance, utilization of a
MET and practice implications.
July 6, 2011
Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse
Events, Nursing Surveillance, Utilization of a MET an…
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psnet.ahrq.gov/node/866869/psn-pdf
October 02, 2024 - Core Elements of Hospital Diagnostic Excellence (DxEx).
October 2, 2024
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
Diagnostic excellence is an expansion of the diagnostic error red…
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digital.ahrq.gov/organization/franklin-foundation-hospital
January 01, 2023 - Franklin Foundation Hospital
Service Integration - 2008
Principal Investigator
Mathews, Craig
Project Name
Service Integration
Service Integration
Description
Built an integrated communications system with area hospitals, clinics…
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psnet.ahrq.gov/node/43601/psn-pdf
December 09, 2015 - Special Focus Issue: Patient Safety.
December 9, 2015
Wagner VD, ed. AORN J. 2014;100:351-456.
https://psnet.ahrq.gov/issue/special-focus-issue-patient-safety
Articles in this special issue explore strategies to establish a culture of safety in health care settings,
including coaching to improve team briefing and …
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psnet.ahrq.gov/node/867695/psn-pdf
March 05, 2025 - The Future of Patient and Family Engagement in Quality
and Patient Safety.
March 5, 2025
The Future of Patient and Family Engagement in Quality and Patient Safety. Front Health Serv. 2024.
https://psnet.ahrq.gov/issue/future-patient-and-family-engagement-quality-and-patient-safety
Patient and family engagement in …
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www.ahrq.gov/topics/education-patient-and-caregiver.html
Topic: Education: Patient and Caregiver
AHRQ has research, tools and resources for clinicians for educating patients and caregivers.
AHRQ Tool Helps Memorial Sloan Kettering Cancer Center Improve Patient Education Materials
Center for Health Literacy Promotion Uses …
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psnet.ahrq.gov/node/33944/psn-pdf
January 29, 2018 - National Patient Safety Foundation.
January 29, 2018
National Patient Safety Foundation.
https://psnet.ahrq.gov/issue/national-patient-safety-foundation
Founded in 1997, the National Patient Safety Foundation supported a variety of initiatives, engaging
multidisciplinary action toward improvement in patient safety…
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psnet.ahrq.gov/node/50643/psn-pdf
November 06, 2019 - Same Day Surgery in the US; Findings of Two Inaugural
Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/same-day-surgery-us-findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of …
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psnet.ahrq.gov/node/38039/psn-pdf
November 03, 2008 - Teamwork in obstetric critical care.
November 3, 2008
Guise J-M, Segel S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynaecol.
2008;22(5):937-51. doi:10.1016/j.bpobgyn.2008.06.010.
https://psnet.ahrq.gov/issue/teamwork-obstetric-critical-care
This article reviews the history of teamwork traini…
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psnet.ahrq.gov/node/43607/psn-pdf
October 15, 2014 - Dallas Ebola case shows even sound plans can fail
spectacularly.
October 15, 2014
Loftis RL. Dallas Morning News. October 5, 2014.
https://psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. Th…
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psnet.ahrq.gov/node/50623/psn-pdf
November 06, 2019 - Adverse Events in Anesthesia: An Integrative Review.
November 6, 2019
Lemos C de S, Poveda V de B. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs.
2019;34(5):978-998. doi:10.1016/j.jopan.2019.02.005.
https://psnet.ahrq.gov/issue/adverse-events-anesthesia-integrative-review
This integrative …
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psnet.ahrq.gov/node/60677/psn-pdf
July 08, 2020 - Optimizing patient safety through system strategies and
patient engagement.
July 8, 2020
Rooprai P, Mistry N. Patient Saf Qual Healthc. June 23, 2020.
https://psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
Health systems are complex environments that require integra…
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psnet.ahrq.gov/node/42861/psn-pdf
January 15, 2014 - Transitioning Newborns From NICU to Home: A Resource
Toolkit.
January 15, 2014
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No.
12(14)-0054-EF.
https://psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit
Infants discharged from the neonatal intensiv…
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psnet.ahrq.gov/node/41396/psn-pdf
May 23, 2012 - In search of common ground in handoff documentation in
an intensive care unit.
May 23, 2012
Collins S, Mamykina L, Jordan D, et al. In search of common ground in handoff documentation in an
Intensive Care Unit. J Biomed Inform. 2012;45(2):307-15. doi:10.1016/j.jbi.2011.11.007.
https://psnet.ahrq.gov/issue/search-c…
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psnet.ahrq.gov/node/45401/psn-pdf
August 17, 2016 - A better safety net for young doctors.
August 17, 2016
Landro L. Wall Street Journal. August. 8, 2016.
https://psnet.ahrq.gov/issue/better-safety-net-young-doctors
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to
demonstrate competency. This newspaper article repo…
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psnet.ahrq.gov/node/39554/psn-pdf
October 13, 2010 - Utilizing information technology to mitigate the handoff
risks caused by resident work hour restrictions.
October 13, 2010
Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks
caused by resident work hour restrictions. Clin Orthop Relat Res. 2010;468(10):2627-32.…
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psnet.ahrq.gov/node/42943/psn-pdf
April 12, 2014 - Doing right by our patients when things go wrong in the
ambulatory setting.
April 12, 2014
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory
setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…
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psnet.ahrq.gov/node/45998/psn-pdf
April 19, 2017 - Learning and mindfulness: improving perioperative
patient safety.
April 19, 2017
Graling PR, Sanchez JA. Learning and mindfulness: improving perioperative patient safety. AORN J.
2017;105(3):317-321. doi:10.1016/j.aorn.2017.01.006.
https://psnet.ahrq.gov/issue/learning-and-mindfulness-improving-perioperative-patie…
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psnet.ahrq.gov/node/50381/psn-pdf
September 25, 2019 - Error disclosure and apology in radiology: the case for
further dialogue.
September 25, 2019
Brown SD, Bruno MA, Shyu JY, et al. Error Disclosure and Apology in Radiology: The Case for Further
Dialogue. Radiology. 2019;293(1):30-35. doi:10.1148/radiol.2019190126.
https://psnet.ahrq.gov/issue/error-disclosure-and-a…
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psnet.ahrq.gov/node/764408/psn-pdf
March 02, 2022 - Ensuring critical instruments and devices are appropriate
for reuse.
March 2, 2022
Quick Safety. February 14, 2022;(64):1-3.
https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …