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psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-moving-research-practice-evaluation-report-ii-2003
May 21, 2014 - Book/Report
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).
Citation Text:
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004). Farley D, Morton SC, Damber…
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psnet.ahrq.gov/issue/building-culture-patient-safety-through-simulation-interprofessional-learning-model
August 21, 2019 - Book/Report
Building a Culture of Patient Safety Through Simulation: An Interprofessional Learning Model.
Citation Text:
Building a Culture of Patient Safety Through Simulation: An Interprofessional Learning Model. Gallo K, Smith LG, eds. New York, NY: Springer Publishing Company; 2015. …
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psnet.ahrq.gov/issue/increasing-demands-quality-measurement
November 16, 2022 - Commentary
Increasing demands for quality measurement.
Citation Text:
Panzer RJ, Gitomer RS, Greene WH, et al. Increasing demands for quality measurement. JAMA. 2013;310(18):1971-80. doi:10.1001/jama.2013.282047.
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psnet.ahrq.gov/issue/emergency-medicine-quality-improvement-and-patient-safety-curriculum
November 30, 2012 - Course Material/Curriculum
Emergency medicine quality improvement and patient safety curriculum.
Citation Text:
Kelly JJ, Thallner E, Broida RI, et al. Emergency Medicine Quality Improvement and Patient Safety Curriculum. Academic Emergency Medicine. 2010;17. doi:10.1111/j.1553-2712.20…
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psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
April 17, 2024 - Newspaper/Magazine Article
Total systems safety supports practitioners in partnering with families to protect patients.
Citation Text:
Total systems safety supports practitioners in partnering with families to protect patients. ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4.
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psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies
April 22, 2016 - Newspaper/Magazine Article
Hospitals slow to adopt patient apology policies.
Citation Text:
Rice S. Hospitals slow to adopt patient apology policies. Modern healthcare. 2015;45(33):16, 29-30.
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psnet.ahrq.gov/issue/considerative-checklist-ensure-safe-daily-patient-review
June 08, 2011 - Commentary
A considerative checklist to ensure safe daily patient review.
Citation Text:
Mohan N, Caldwell G. A Considerative Checklist to ensure safe daily patient review. Clin Teach. 2013;10(4):209-13. doi:10.1111/tct.12023.
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psnet.ahrq.gov/issue/impact-abbreviations-patient-safety
January 02, 2017 - Study
The impact of abbreviations on patient safety.
Citation Text:
Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Jt Comm J Qual Patient Saf. 2007;33(9):576-83.
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psnet.ahrq.gov/issue/tolerance-uncertainty-and-practice-emergency-medicine
May 25, 2022 - Commentary
Tolerance of uncertainty and the practice of emergency medicine.
Citation Text:
Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of uncertainty and the practice of emergency medicine. Ann Emerg Med. 2020;75(6):715-720. doi:10.1016/j.annemergmed.2019.10.015.
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psnet.ahrq.gov/issue/missed-injuries-trauma-patients-literature-review
April 01, 2009 - Review
Missed injuries in trauma patients: a literature review.
Citation Text:
Pfeifer R, Pape H-C. Missed injuries in trauma patients: A literature review. Patient Saf Surg. 2008;2:20. doi:10.1186/1754-9493-2-20.
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-medication-safety
January 19, 2011 - Commentary
Implementing AORN recommended practices for medication safety.
Citation Text:
Hicks RW, Wanzer LJ, Denholm B. Implementing AORN recommended practices for medication safety. AORN J. 2012;96(6):605-22. doi:10.1016/j.aorn.2012.09.012.
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psnet.ahrq.gov/issue/emperors-new-clothes-or-whatever-happened-human-error
March 27, 2005 - Meeting/Conference Proceedings
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?
Citation Text:
The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed. Proceedings of the 4th International Workshop…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/curated-library/diagnostic-error
November 03, 2025 - Breadcrumb
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Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - had implemented a system that had a specific purpose, and it was extremely successful at preventing deaths … patient safety issue in the inpatient setting; research estimates between 10% and 13% of patient hospital deaths