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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - in their ability to take in new information probably do need someone—whether you label that person a coordinator
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - in their ability to take in new information probably do need someone—whether you label that person a coordinator
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psnet.ahrq.gov/node/35048/psn-pdf
June 22, 2009 - Reduction in warfarin adverse events requiring patient
hospitalization after implementation of a pharmacist-
managed anticoagulation service.
June 22, 2009
Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization
after implementation of a pharmacist-managed anticoa…
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psnet.ahrq.gov/node/45015/psn-pdf
July 18, 2016 - Interhospital transfer handoff practices among US tertiary
care centers: a descriptive survey.
July 18, 2016
Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care
centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577.
https://psnet.ahr…
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psnet.ahrq.gov/node/46006/psn-pdf
May 03, 2017 - Creating a Pediatric Joint Council to promote patient
safety and quality, governance, and accountability across
Johns Hopkins Medicine.
May 3, 2017
Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety
and Quality, Governance, and Accountability Across Johns Hopkins…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/43184/psn-pdf
May 14, 2014 - Often overlooked problems with handoffs: from the
intensive care unit to the operating room.
May 14, 2014
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to
the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/node/44638/psn-pdf
May 18, 2016 - Developing an appreciation of patient safety: analysis of
interprofessional student experiences with health
mentors.
May 18, 2016
Langlois S. Developing an appreciation of patient safety: analysis of interprofessional student experiences
with health mentors. Perspect Med Educ. 2016;5(2):88-94. doi:10.1007/s40037-0…
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psnet.ahrq.gov/node/60866/psn-pdf
January 01, 2022 - Association of implementation and social network factors
with patient safety culture in medical homes: a
coincidence analysis.
September 2, 2020
Dy SM, Acton RM, Yuan CT, et al. Association of implementation and social network factors with patient
safety culture in medical homes: a coincidence analysis. J Patient …
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psnet.ahrq.gov/node/60867/psn-pdf
September 02, 2020 - Clarifying radiology's role in safety events: a 5-year
retrospective common cause analysis of safety events at
a pediatric hospital.
September 2, 2020
Khalatbari H, Menashe SJ, Otto RK, et al. Clarifying radiology’s role in safety events: a 5-year retrospective
common cause analysis of safety events at a pediatric…
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psnet.ahrq.gov/node/72530/psn-pdf
January 01, 2021 - A realist synthesis of pharmacist-conducted medication
reviews in primary care after leaving hospital: what works
for whom and why?
December 2, 2020
Luetsch K, Rowett D, Twigg MJ. A realist synthesis of pharmacist-conducted medication reviews in primary
care after leaving hospital: what works for whom and why? BMJ…
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psnet.ahrq.gov/node/60645/psn-pdf
July 01, 2020 - How health care systems let our patients down: a
systematic review into suicide deaths.
July 1, 2020
Wyder M, Ray MK, Roennfeldt H, et al. How health care systems let our patients down: a systematic review
into suicide deaths. Int J Qual Health Care. 2020;32(5):285-291. doi:10.1093/intqhc/mzaa011.
https://psnet.ah…
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psnet.ahrq.gov/node/849332/psn-pdf
May 24, 2023 - Analysis of reported suicide safety events among
veterans who received treatment through Department of
Veterans Affairs-contracted community care.
May 24, 2023
Riblet NB, Soncrant C, Mills PD, et al. Analysis of reported suicide safety events among veterans who
received treatment through Department of Veterans Aff…
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psnet.ahrq.gov/node/73425/psn-pdf
June 23, 2021 - A qualitative study of what care workers do to provide
patient safety at home through telecare.
June 23, 2021
Stokke R, Melby L, Isaksen J, et al. A qualitative study of what care workers do to provide patient safety at
home through telecare. BMC Health Serv Res. 2021;21(1):553. doi:10.1186/s12913-021-06556-4.
htt…
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psnet.ahrq.gov/node/74229/psn-pdf
January 12, 2022 - A simulation systems testing program using HFMEA
methodology can effectively identify and mitigate latent
safety threats for a new on-site helipad.
January 12, 2022
Holmes J, Chipman M, Barbour T, et al. A simulation systems testing program using HFMEA methodology
can effectively identify and mitigate latent safet…
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psnet.ahrq.gov/node/72637/psn-pdf
January 13, 2021 - Identifying factors leading to harm in English general
practices: a mixed-methods study based on patient
experiences integrating structural equation modeling and
qualitative content analysis.
January 13, 2021
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factors Leading to Harm in English
G…
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psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
May 01, 2015 - Book/Report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Citation Text:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/african-partnerships-patient-safety
April 30, 2024 - Multi-use Website
African Partnerships for Patient Safety.
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November 11, 2009
This Web site establishes a forum for hospitals in E…
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psnet.ahrq.gov/node/867750/psn-pdf
March 12, 2025 - Doing 'detective work' to find a cancer: how are non-
specific symptom pathways for cancer investigation
organised, and what are the implications for safety and
quality of care? A multisite qualitative approach.
March 12, 2025
Black GB, Nicholson BD, Moreland J-A, et al. Doing ‘detective work’ to find a cancer: ho…