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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - The concept of Root Cause Analysis and Action (RCA2) emphasizes that the processes of analyzing and
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - What do you think about that concept and how does Lean approach that issue of management by walking around … Standard work is a particularly troublesome concept to many health care professionals.
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psnet.ahrq.gov/issue/safety-numbers-development-leapfrogs-composite-patient-safety-score-us-hospitals
November 03, 2015 - Study
Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals.
Citation Text:
Austin M, D'Andrea G, Birkmeyer JD, et al. Safety in numbers: the development of Leapfrog's composite patient safety score for U.S. hospitals. J Patient Saf. 2014;10(1):…
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psnet.ahrq.gov/issue/making-health-care-safer-ii-updated-critical-analysis-evidence-patient-safety-practices
March 13, 2013 - Book/Report
Classic
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Citation Text:
Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer Ii: An Updated Critical Analysis Of The Evidence For…
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psnet.ahrq.gov/issue/bridging-leadership-roles-quality-and-patient-safety-experience-6-us-academic-medical-centers
September 04, 2016 - Study
Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers.
Citation Text:
Myers JS, Tess A, McKinney K, et al. Bridging Leadership Roles in Quality and Patient Safety: Experience of 6 US Academic Medical Centers. J Grad Med Educ. 2017;9(1)…
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psnet.ahrq.gov/issue/early-death-after-discharge-emergency-departments-analysis-national-us-insurance-claims-data
June 25, 2018 - Study
Classic
Early death after discharge from emergency departments: analysis of national US insurance claims data.
Citation Text:
Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis of national US insurance cl…
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psnet.ahrq.gov/issue/unprofessional-behaviors-among-tomorrows-physicians-review-literature-focus-risk-factors
January 31, 2018 - Review
Unprofessional behaviors among tomorrow's physicians: review of the literature with a focus on risk factors, temporal trends, and future directions.
Citation Text:
Fargen KM, Drolet BC, Philibert I. Unprofessional Behaviors Among Tomorrow's Physicians: Review of the Literature Wit…
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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Citation Text:
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - What was the patient's concept of what was wrong with him?
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - Proposing a transactional model of eHealth literacy: concept analysis.
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - works in one context may actually be detrimental in another. 6,8
Situated cognition is another concept
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - The concept of failure to rescue was something that I got interested in 1992 when Jeff Silber published … I was interested in the concept of recovering and tolerating incidents and accidents rather than just
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - However, as a general concept AI refers to a computer applying human intellectual characteristics to … DG: I think AI is a really broad concept.
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Sarah Mossburg: Please start our conversation today by explaining the concept of zero harm. … Other people use it more as an abstract concept, something that we aspire to—zero harm, but not necessarily
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psnet.ahrq.gov/about-psnet
September 01, 2015 - About PSNet AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings ("Current Issue"), and a vast set of carefully annotated links to important researc…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - Book/Report
Textbook of Rapid Response Systems: Concept and Implementation.
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psnet.ahrq.gov/perspective/building-capacity-patient-safety
July 31, 2023 - Building Capacity for Patient Safety
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD
| July 31, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hoffman R, Mossburg S, Van CM. Build…
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - agents contributed to administration errors. 4 Human factors engineering principles support the concept