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psnet.ahrq.gov/node/73471/psn-pdf
July 07, 2021 - Rapid response teams as a patient safety practice for
failure to rescue.
July 7, 2021
Fischer CP, Bilimoria KY, Ghaferi AA. Rapid Response Teams as a Patient Safety Practice for Failure to
Rescue. JAMA. 2021;326(2):179-180. doi:10.1001/jama.2021.7510.
https://psnet.ahrq.gov/issue/rapid-response-teams-patient-safet…
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psnet.ahrq.gov/node/45622/psn-pdf
December 07, 2016 - National Partnership for Maternal Safety: Consensus
Bundle on Venous Thromboembolism.
December 7, 2016
D'Alton ME, Friedman AM, Smiley RM, et al. National Partnership for Maternal Safety: Consensus Bundle
on Venous Thromboembolism. J Obstet Gynecol Neonatal Nurs. 2016;45(5):706-717.
doi:10.1016/j.jogn.2016.07.001.…
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psnet.ahrq.gov/node/73280/psn-pdf
May 19, 2021 - Rates of serious surgical errors in California and plans to
prevent recurrence.
May 19, 2021
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent
recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058.
https://psnet.ahrq.gov/issue/rates-…
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psnet.ahrq.gov/node/72654/psn-pdf
January 20, 2020 - What is an ethically informed approach to managing
patient safety risk during discharge planning?
January 20, 2020
West JC. What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge
Planning? AMA J Ethics. 2020;22(!1):e919-e923. doi:10.1001/amajethics.2020.919.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/73714/psn-pdf
September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
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psnet.ahrq.gov/node/73912/psn-pdf
October 06, 2021 - The Contribution of Diagnostic Errors to Maternal
Morbidity and Mortality During and Immediately After
Childbirth: State of the Science.
October 6, 2021
Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality;
September 2021. AHRQ Publication No. 20(21)-0040-6-EF.
https://ps…
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psnet.ahrq.gov/node/50589/psn-pdf
October 30, 2019 - Missed serious neurologic conditions in emergency
department patients discharged with nonspecific
diagnoses of headache or back pain.
October 30, 2019
Dubosh NM, Edlow JA, Goto T, et al. Missed Serious Neurologic Conditions in Emergency Department
Patients Discharged With Nonspecific Diagnoses of Headache or Back …
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psnet.ahrq.gov/node/861778/psn-pdf
January 31, 2024 - Care Deficiencies and Leaders' Inadequate Reviews of a
Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA
Medical Center in Memphis, Tennessee.
January 31, 2024
Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52.
https://psnet.ahrq.gov/issue/care-deficiencies-and-l…
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psnet.ahrq.gov/node/853073/psn-pdf
August 30, 2023 - Mind the power gap: how hierarchical leadership in
healthcare is a risk to patient safety.
August 30, 2023
Kanaris C. Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety. J Child
Health Care. 2023;27(3):319-322. doi:10.1177/13674935231196197.
https://psnet.ahrq.gov/issue/mind-…
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psnet.ahrq.gov/node/40220/psn-pdf
March 21, 2012 - Incidence and preventability of adverse events requiring
intensive care admission: a systematic review.
March 21, 2012
Vlayen A, Verelst S, Bekkering GE, et al. Incidence and preventability of adverse events requiring intensive
care admission: a systematic review. J Eval Clin Pract. 2012;18(2):485-97. doi:10.1111/j…
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psnet.ahrq.gov/node/849605/psn-pdf
May 31, 2023 - Identification of patient safety threats in a post-intensive
care clinic.
May 31, 2023
Karlic KJ, Valley TS, Cagino LM, et al. Identification of patient safety threats in a post-intensive care clinic.
Am J Med Qual. 2023;38(3):117-121. doi:10.1097/jmq.0000000000000118.
https://psnet.ahrq.gov/issue/identification-p…
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psnet.ahrq.gov/node/44681/psn-pdf
April 13, 2016 - Triggers, bundles, protocols, and checklists—what every
maternal care provider needs to know.
April 13, 2016
Arora KS, Shields LE, Grobman WA, et al. Triggers, bundles, protocols, and checklists--what every
maternal care provider needs to know. Am J Obstet Gynecol. 2016;214(4):444-451.
doi:10.1016/j.ajog.2015.10.0…
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psnet.ahrq.gov/node/61077/psn-pdf
October 28, 2020 - Investigation into the Role of Clinical Pharmacy Services
in Helping to Identify and Reduce High-risk Prescribing
Errors in Hospital.
October 28, 2020
Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.
https://psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-servi…
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psnet.ahrq.gov/node/866245/psn-pdf
July 10, 2024 - Assessing nourishment problems at a hospital: what can
we learn from them?
July 10, 2024
Clausen MK, Bogh SB, Schmidt-Petersen M, et al. Assessing nourishment problems at a hospital: what
can we learn from them? BMJ Open Qual. 2024;13(2):e002745. doi:10.1136/bmjoq-2024-002745.
https://psnet.ahrq.gov/issue/assessin…
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psnet.ahrq.gov/node/72643/psn-pdf
January 13, 2021 - Ockenden Report. Emerging Fndings and
Recommendations from the Independent Review of
Maternity Services at the Shrewsbury and Telford
Hospital NHS Trust.
January 13, 2021
London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.
https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/suicide-risk-in-adolescents-adults-and-older-adults-screening
May 20, 2014 - Rates of suicide attempts and deaths vary by sex, age, and race or ethnicity 1 . … per 100,000]) and those aged 55 to 59 years (47.8% [from 20.3 to 30.0 deaths per 100,000]). … rate in men increased by 39.6% (from 24.5 to 34.2 deaths per 100,000) 9 . … at a rate of 11.8 deaths per 100,000 persons 1 . … Deaths: Final Data for 2010. Natl Vital Stat Rep . 2013;61:1-117.
2.
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hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit5_3.jsp
January 01, 2007 - Four percent of stays resulted in in-hospital deaths and less than 1 percent were discharges against … Less than 1 percent of Medicaid, private insurance, and uninsured stays resulted in in-hospital deaths … For stays with Medicare as the primary payer, in-hospital deaths occurred in 4 percent of stays.
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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - Prior studies have found that nearly 8% of deaths in
patients with major trauma may be preventable, … lost-information-during-handover-critically-injured-trauma-patients-mixed-methods-study
https://psnet.ahrq.gov/issue/classifying-errors-preventable-and-potentially-preventable-trauma-deaths
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psnet.ahrq.gov/node/38837/psn-pdf
June 28, 2011 - validity-selected-ahrq-patient-safety-indicators-based-va-national-surgical-quality
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
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psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
January 27, 2021 - Book/Report
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.
Citation Text:
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
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