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psnet.ahrq.gov/issue/implementation-sbar-communication-technique-tertiary-center
March 27, 2019 - Commentary
Implementation of the SBAR communication technique in a tertiary center.
Citation Text:
Woodhall LJ, Vertacnik L, McLaughlin M. Implementation of the SBAR Communication Technique in a Tertiary Center. J Emerg Nurs. 2008;34(4):314-317. doi:10.1016/j.jen.2007.07.007.
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psnet.ahrq.gov/issue/bias-radiology-how-and-why-misses-and-misinterpretations
March 01, 2023 - Commentary
Bias in radiology: the how and why of misses and misinterpretations.
Citation Text:
Busby LP, Courtier JL, Glastonbury CM. Bias in Radiology: The How and Why of Misses and Misinterpretations. Radiographics. 2018;38(1):236-247. doi:10.1148/rg.2018170107.
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psnet.ahrq.gov/issue/computerized-provider-order-entry-and-prescribing-and-evidence-safe-practice-update-clinical
November 03, 2015 - Review
Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse specialist.
Citation Text:
O'Malley P. Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse speciali…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/o_ShfFEXnZSZ7bfsDWvjCx
August 01, 2023 - Folic Acid Supplementation to Prevent Neural Tube Defects
USPSTF Clinician Summary of USPSTF Recommendation
Folic Acid Supplementation to Prevent Neural Tube Defects
August 2023
What does the USPSTF recommend?
A
Grade
Persons who plan to or could become pregnant:
Take a daily supplement containing 0.4 to 0.8 mg …
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psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety
September 07, 2022 - Newspaper/Magazine Article
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.
Citation Text:
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. ISMP Medication Safety Alert! Acut…
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psnet.ahrq.gov/issue/physicians-multiple-patient-complaints-ending-our-silence
June 01, 2004 - Commentary
Physicians with multiple patient complaints: ending our silence.
Citation Text:
Gallagher TH, Levinson W. Physicians with multiple patient complaints: ending our silence. BMJ Qual Saf. 2013;22(7):521-4. doi:10.1136/bmjqs-2013-001880.
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psnet.ahrq.gov/issue/hospital-mortality-when-failure-not-good-measure-success
December 22, 2010 - Commentary
Hospital mortality: when failure is not a good measure of success.
Citation Text:
Shojania KG, Forster AJ. Hospital mortality: when failure is not a good measure of success. CMAJ. 2008;179(2):153-7. doi:10.1503/cmaj.080010.
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DOI Google Scho…
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psnet.ahrq.gov/issue/national-safety-board-made-transportation-safer-and-could-do-same-health-care-advocates-say
August 09, 2023 - Newspaper/Magazine Article
A national safety board made transportation safer and could do the same for health care, advocates say.
Citation Text:
A national safety board made transportation safer and could do the same for health care, advocates say. Jaklevic MC. CNN. May 30, 2023.
Co…
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psnet.ahrq.gov/issue/high-reliability-organizations-hros-what-they-know-we-dont-part-ii
June 10, 2018 - Newspaper/Magazine Article
High-reliability organizations (HROs): what they know that we don't (Part II).
Citation Text:
High-reliability organizations (HROs): what they know that we don't (Part II). ISMP Medication Safety Alert! Acute Care Edition. July 28, 2005;10:1-3.
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www.ahrq.gov/cahps/consumer-reporting/guidelines/contents/index.html
March 01, 2016 - Contents of a CAHPS Report
One of the first steps in producing a CAHPS report is to decide what information to include. This page offers a brief overview of the kinds of information you may want to share with your audience.
To learn more about the topics to cover in a quality report, go to Explain and Motiva…
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psnet.ahrq.gov/issue/systems-science-primer-high-reliability
March 23, 2022 - Review
Systems science: a primer on high reliability.
Citation Text:
Roberson DW, Kirsh ER. Systems science: a primer on high reliability. Otolaryngol Clin North Am. 2019;52(1):1-9. doi:10.1016/j.otc.2018.08.001.
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www.ahrq.gov/cpi/about/nac/snac-pronovost.html
December 01, 2021 - SNAC Member: Peter Pronovost, M.D., Ph.D.
Chief Quality and Clinical Transformation Officer, University Hospitals
Professor, Department of Anesthesiology and Critical Care Medicine, School of Medicine and School of Nursing
Case Western Reserve University
Peter Pronovost, M.D., Ph.D., is a patient safety cha…
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psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review
October 14, 2020 - Review
Emerging Classic
Incident learning in radiation oncology: a review.
Citation Text:
Ford E, Evans SB. Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119. doi:10.1002/mp.12800.
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psnet.ahrq.gov/issue/acting-locally-working-clinical-microsystems-cd-rom
May 20, 2019 - Special or Theme Issue
Acting Locally: Working in Clinical Microsystems CD-ROM.
Citation Text:
Acting Locally: Working in Clinical Microsystems CD-ROM. Oakbrook Terrance, IL: Joint Commission Resources; 2005. ISBN 9780866889865.
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psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition
May 12, 2010 - Book/Report
Classic
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition.
Citation Text:
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. Senge PM. New York, NY: Currenc…
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psnet.ahrq.gov/node/37542/psn-pdf
February 23, 2018 - A past PSNet perspective discussed the application
of human factors engineering concepts.
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psnet.ahrq.gov/node/43815/psn-pdf
February 04, 2015 - The concepts explored in this study have been used to develop a patient safety curriculum
that is being
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psnet.ahrq.gov/node/46450/psn-pdf
August 20, 2018 - domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized
measure concepts
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psnet.ahrq.gov/node/43655/psn-pdf
December 19, 2014 - These four concepts can serve as a theoretical framework for future empiric work to characterize and
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psnet.ahrq.gov/node/39293/psn-pdf
June 11, 2010 - Collaboration and communication between team members are key determinants of safety culture, but these
concepts