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psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
February 17, 2017 - Newspaper/Magazine Article
Could it happen here? Learning from other organizations' safety errors.
Citation Text:
Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/acog-committee-opinion-546-tracking-and-reminder-systems
May 22, 2019 - Commentary
ACOG Committee Opinion #546: tracking and reminder systems.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee Opinion No.546: Tracking and reminder systems. Obstet Gynecol. 2012;120(6):1535-7. doi:10.1097/01.AOG.0000423820.92906.d0.
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psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
June 07, 2018 - Commentary
Hidden danger, obvious opportunity: error and risk in the management of cancer.
Citation Text:
Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66.
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psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-quality-r18
March 08, 2023 - Grant Announcement
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).
Citation Text:
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). Rockville, MD: Agency for Healthcare Research and Quality; April…
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psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
June 10, 2018 - Newspaper/Magazine Article
Multiple latent failures align to allow a serious drug interaction to harm a patient.
Citation Text:
Multiple latent failures align to allow a serious drug interaction to harm a patient. ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/pridx-framework-engage-payers-reducing-diagnostic-errors-healthcare
January 22, 2025 - Commentary
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
Citation Text:
Ali KJ, Goeschel CA, DeLia DM, et al. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl). 2024;11(1):17-24. doi:10.1515/dx-2023-0042…
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psnet.ahrq.gov/issue/twelve-tips-engaging-learners-checking-health-care-decisions
February 27, 2014 - Commentary
Twelve tips on engaging learners in checking health care decisions.
Citation Text:
Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910.
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psnet.ahrq.gov/issue/healthgrades-sixth-annual-patient-safety-american-hospitals-study
October 25, 2013 - Book/Report
HealthGrades Sixth Annual Patient Safety in American Hospitals Study.
Citation Text:
HealthGrades Sixth Annual Patient Safety in American Hospitals Study. Golden, CO: HealthGrades, Inc.; April 2009.
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psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire
February 11, 2009 - Commentary
A just culture after Mid Staffordshire.
Citation Text:
Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. doi:10.1136/bmjqs-2013-002483.
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psnet.ahrq.gov/issue/insulin-treatment-tracer-identifying-latent-patient-safety-risks-home-based-diabetes-care
September 28, 2010 - Study
Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care.
Citation Text:
Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care. Odegard S; Andersson DK. J Nurs Manag. 2006;14(2):116-127…
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psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
January 05, 2017 - Study
Awareness and use of a cognitive aid for anesthesiology.
Citation Text:
Neily J, DeRosier JM, Mills PD, et al. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Patient Saf. 2007;33(8):502-11.
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psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers-and-improve
July 22, 2024 - Meeting/Conference Proceedings
Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety.
Citation Text:
Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety. Agency for Healthcare Research a…
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psnet.ahrq.gov/issue/measurement-and-training-teamstepps-dimensions-using-medical-team-performance-assessment-tool
March 09, 2009 - Commentary
Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool.
Citation Text:
Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people
September 08, 2021 - Newspaper/Magazine Article
To improve health care, focus on fixing systems — not people.
Citation Text:
Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024;
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psnet.ahrq.gov/issue/racial-ethnic-and-payer-disparities-adverse-safety-events-are-there-differences-across
December 01, 2019 - Book/Report
Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?
Citation Text:
Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? Gangopa…
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/patient-safety-education-what-was-what-and-what-will-be
April 10, 2019 - Commentary
Patient safety education: what was, what is, and what will be?
Citation Text:
Klamen D, Sanserino K, Skolnik PJ. Patient Safety Education: What Was, What Is, and What Will Be? Teach Learn Med. 2013;25(sup1). doi:10.1080/10401334.2013.842906.
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