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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Rather than attempting to compress this comprehensive series into a brief commentary, the discussion … this relatively poor agreement, how does one assign the final outcome for each case—majority rules or discussion
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psnet.ahrq.gov/issue/enhancing-your-medication-error-reporting-program-improve-global-medication-safety
June 10, 2018 - Webinar
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety.
Citation Text:
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. Institute for Safe Medication Practices. September 15, 2020.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - so the fact that this was a "scheduled" case should have prompted a more thorough investigation and discussion
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psnet.ahrq.gov/issue/why-diagnostic-errors-dont-get-any-respect-and-what-can-be-done-about-them
February 10, 2015 - Commentary
Why diagnostic errors don't get any respect--and what can be done about them.
Citation Text:
Wachter RM. Why Diagnostic Errors Don’t Get Any Respect—And What Can Be Done About Them. Health Aff (Millwood). 2010;29(9):1605-1610. doi:10.1377/hlthaff.2009.0513.
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - Book/Report
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.
Citation Text:
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.
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psnet.ahrq.gov/issue/surveys-patient-safety-culture
December 24, 2008 - Measurement Tool/Indicator
Classic
Surveys on Patient Safety Culture.
Citation Text:
Surveys on Patient Safety Culture. Rockville MD: Agency for Healthcare Research and Quality
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psnet.ahrq.gov/issue/mindless-mindful-practice-cognitive-bias-and-clinical-decision-making
November 23, 2016 - Commentary
From mindless to mindful practice—cognitive bias and clinical decision making.
Citation Text:
Croskerry P. From mindless to mindful practice--cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445-2448. doi:10.1056/NEJMp1303712.
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psnet.ahrq.gov/issue/physician-burnout
May 01, 2017 - Book/Report
Physician Burnout.
Citation Text:
Physician Burnout. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
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psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
February 09, 2011 - Commentary
Classic
Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.
Citation Text:
Structural and organizational issues in patient safety: a comparison of health care to other high-hazard indust…
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psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
June 01, 2014 - Special or Theme Issue
Improving patient safety by shifting power from health professionals to patients.
Citation Text:
Improving patient safety by shifting power from health professionals to patients. BMJ. 2023(383):2219, 2278, 2319, 2331.
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psnet.ahrq.gov/issue/call-excellence
May 20, 2009 - Commentary
A call to excellence.
Citation Text:
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
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psnet.ahrq.gov/issue/medication-safety-look-alike-sound-alike-medicines
November 19, 2014 - Book/Report
Medication Safety for Look-alike, Sound-alike Medicines.
Citation Text:
Medication Safety for Look-alike, Sound-alike Medicines. Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.
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psnet.ahrq.gov/issue/problem-doctors-there-system-level-solution
October 31, 2014 - Commentary
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Problem doctors: is there a system-level solution?
Citation Text:
Leape L, Fromson J. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-15.
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psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
February 15, 2017 - Book/Report
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events.
Citation Text:
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
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psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center-transforming
October 19, 2016 - Book/Report
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Citation Text:
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. Chi…
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psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
November 01, 2012 - Study
Reconciliation failures lead to medication errors.
Citation Text:
Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9.
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psnet.ahrq.gov/issue/creating-fair-and-just-culture-one-institutions-path-toward-organizational-change
July 23, 2014 - Commentary
Creating a fair and just culture: one institution's path toward organizational change.
Citation Text:
Connor M, Duncombe D, Barclay E, et al. Creating a fair and just culture: one institution's pat toward organizational change. Jt Comm J Qual Patient Saf. 2007;33(10):617-24.
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psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
September 01, 2006 - As this discussion suggests, managing anesthesia in obese patients requires careful attention and understanding
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - His case prompted extensive discussion of infection control procedures among the ED leadership, given
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient