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psnet.ahrq.gov/node/40955/psn-pdf
March 08, 2017 - Kaiser Permanente's performance improvement system,
part 4: creating a learning organization.
March 8, 2017
Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4:
Creating a learning organization. Jt Comm J Qual Patient Saf. 2011;37(12):532-43.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/37596/psn-pdf
May 01, 2016 - Patient Safety Organization (PSO) Program.
May 1, 2016
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient
care," the Agency for Healthcare Research…
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psnet.ahrq.gov/node/836868/psn-pdf
April 06, 2022 - HEAR Her Concerns.
April 6, 2022
National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health;
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/hear-her-concerns
Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…
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psnet.ahrq.gov/node/45856/psn-pdf
April 12, 2018 - NAM Action Collaborative on Clinician Well-Being and
Resilience.
April 12, 2018
Washington, DC: National Academy of Medicine.
https://psnet.ahrq.gov/issue/nam-action-collaborative-clinician-well-being-and-resilience
Clinician burnout can affect the ability of individuals to act safely. This website highlights the …
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psnet.ahrq.gov/node/37176/psn-pdf
January 02, 2017 - Using an automated risk assessment report to identify
patients at risk for clinical deterioration.
January 2, 2017
Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at
risk for clinical deterioration. Jt Comm J Qual Patient Saf. 2007;33(9):569-74.
https://psnet.…
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psnet.ahrq.gov/node/45590/psn-pdf
August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017.
August 2, 2017
Washington, DC: National Quality Forum; October 2016.
https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017
The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable
diagnosis. This we…
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psnet.ahrq.gov/node/45169/psn-pdf
June 08, 2016 - High Reliability in Health Care.
June 8, 2016
Joint Commission Center for Transforming Healthcare.
https://psnet.ahrq.gov/issue/high-reliability-health-care
Development of high reliability remains an elusive goal for health care organizations. The Joint Commission
has also advocated for achieving high reliability …
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psnet.ahrq.gov/node/867532/psn-pdf
January 15, 2025 - Maternal Health Indicators.
January 15, 2025
Maternal Health Indicators. Agency for Healthcare Quality and Research. 2024.
https://psnet.ahrq.gov/issue/maternal-health-indicators
Maternal health care faces a variety of patient safety challenges. This set of quality indicators supports the
epidemiological or resear…
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psnet.ahrq.gov/node/45931/psn-pdf
July 05, 2017 - The CARE approach to reducing diagnostic errors.
July 5, 2017
Rush JL, Helms SE, Mostow EN. The CARE approach to reducing diagnostic errors. Int J Dermatol.
2017;56(6):669-673. doi:10.1111/ijd.13532.
https://psnet.ahrq.gov/issue/care-approach-reducing-diagnostic-errors
Cognitive aids such as checklists and mnemoni…
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psnet.ahrq.gov/node/862616/psn-pdf
February 14, 2024 - Engaging Patients for Patient Safety: Advocacy Brief.
February 14, 2024
WHO Patient Safety Flagship. Geneva; World Health Organization; December 2023. ISBN:
9789240081987.
https://psnet.ahrq.gov/issue/engaging-patients-patient-safety-advocacy-brief
Patients and families are important, yet underutilized, partn…
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psnet.ahrq.gov/node/44091/psn-pdf
January 04, 2019 - Isolation precautions for visitors.
January 4, 2019
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp
Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
https://psnet.ahrq.gov/issue/isolation-precautions-visitors
This expert guidance provides recommendations …
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psnet.ahrq.gov/node/40742/psn-pdf
May 28, 2014 - Implementation of a protocol to reduce occurrence of
retained sponges after vaginal delivery.
May 28, 2014
Lutgendorf MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained
sponges after vaginal delivery. Mil Med. 2011;176(6):702-704.
https://psnet.ahrq.gov/issue/implementa…
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psnet.ahrq.gov/node/39050/psn-pdf
January 04, 2010 - Safety as a criterion for quality: The Critical Nursing
Situation Index in paediatric critical care, an observational
study.
January 4, 2010
de Neef M, Bos AP, Tol D. Safety as a criterion for quality: the critical nursing situation index in paediatric
critical care, an observational study. Intensive Crit Care Nur…
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psnet.ahrq.gov/node/43607/psn-pdf
October 15, 2014 - Dallas Ebola case shows even sound plans can fail
spectacularly.
October 15, 2014
Loftis RL. Dallas Morning News. October 5, 2014.
https://psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. Th…
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psnet.ahrq.gov/node/40447/psn-pdf
March 04, 2015 - Analysis and prioritization of near-miss adverse events in
a radiology department.
March 4, 2015
Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a
radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/36547/psn-pdf
January 10, 2011 - The power of collaboration with patient safety programs:
building safe passage for patients, nurses, and clinical
staff.
January 10, 2011
Kerfoot KM, Rapala K, Ebright PR, et al. The power of collaboration with patient safety programs: building
safe passage for patients, nurses, and clinical staff. J Nurs Adm. 200…
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psnet.ahrq.gov/node/42974/psn-pdf
September 07, 2016 - Chemotherapy drug shortages in pediatric oncology: a
consensus statement.
September 7, 2016
Decamp M, Joffe S, Fernandez C, et al. Chemotherapy drug shortages in pediatric oncology: a consensus
statement. Pediatrics. 2014;133(3):e716-24. doi:10.1542/peds.2013-2946.
https://psnet.ahrq.gov/issue/chemotherapy-drug-sh…
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psnet.ahrq.gov/node/36337/psn-pdf
October 26, 2010 - Technology, governance and patient safety: systems
issues in technology and patient safety.
October 26, 2010
Balka E, Doyle-Waters M, Lecznarowicz D, et al. Technology, governance and patient safety: systems
issues in technology and patient safety. Int J Med Inform. 2007;76 Suppl 1:S35-47.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/39440/psn-pdf
September 19, 2016 - Toward understanding errors in inpatient psychiatry: a
qualitative inquiry.
September 19, 2016
Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry.
Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z.
https://psnet.ahrq.gov/issue/toward-understanding…
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psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - The misery of a doctor's first days.
October 14, 2015
Hester JL. The Atlantic. October 1, 2015.
https://psnet.ahrq.gov/issue/misery-doctors-first-days
Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine
the difficulties associated with the first days of pra…