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psnet.ahrq.gov/node/42434/psn-pdf
September 29, 2017 - Building bridges: future directions for medical error
disclosure research.
September 29, 2017
Hannawa AF, Beckman H, Mazor KM, et al. Building bridges: future directions for medical error disclosure
research. Patient Educ Couns. 2013;92(3):319-327. doi:10.1016/j.pec.2013.05.017.
https://psnet.ahrq.gov/issue/buildi…
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psnet.ahrq.gov/node/60710/psn-pdf
July 22, 2020 - Lessons from walking the medical distancing tightrope.
July 22, 2020
Jenkins I, Sebasky M, Bell J, et al. Lessons from walking the medical distancing tightrope. Jt Comm J Qual
Patient Saf. 2020;46(9):542-545. doi:10.1016/j.jcjq.2020.05.006.
https://psnet.ahrq.gov/issue/lessons-walking-medical-distancing-tightrope
…
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psnet.ahrq.gov/node/43215/psn-pdf
May 28, 2014 - When medical students make errors.
May 28, 2014
https://psnet.ahrq.gov/issue/when-medical-students-make-errors
This newspaper article highlights the need for medical students to be educated about how to disclose
errors to patients and families when mistakes occur, even if the patient was not harmed.
https://psnet.…
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psnet.ahrq.gov/node/48038/psn-pdf
June 05, 2019 - Addressing Problematic Opioid Use in OECD Countries.
June 5, 2019
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN:
978926474260.
https://psnet.ahrq.gov/issue/addressing-problematic-opioid-use-oecd-countries
The overprescribing of prescription opioids heightens the…
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psnet.ahrq.gov/node/44429/psn-pdf
May 10, 2016 - Teaching Clinical Reasoning.
May 10, 2016
Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Philadelphia, PA: American College of Physicians; 2015.
ISBN: 9781938921056.
https://psnet.ahrq.gov/issue/teaching-clinical-reasoning
Diagnostic errors are often attributed to clinicians' cognitive biases. This publication prov…
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psnet.ahrq.gov/node/48183/psn-pdf
August 07, 2019 - Get the Medications Right Institute.
August 7, 2019
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
https://psnet.ahrq.gov/issue/get-medications-right-institute
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure
reliable medication use. This institute supports m…
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psnet.ahrq.gov/node/41238/psn-pdf
March 21, 2012 - Restricting resident work hours: the good, the bad, and
the ugly.
March 21, 2012
Peets A, Ayas N. Restricting resident work hours: the good, the bad, and the ugly. Crit Care Med.
2012;40(3):960-6. doi:10.1097/CCM.0b013e3182413bc5.
https://psnet.ahrq.gov/issue/restricting-resident-work-hours-good-bad-and-ugly
This…
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psnet.ahrq.gov/node/36828/psn-pdf
August 29, 2011 - Pediatric medication errors in the postanesthesia care
unit: analysis of MEDMARX data.
August 29, 2011
Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit:
analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4.
https://psnet.ahrq.gov/issue/pediatric-medicati…
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psnet.ahrq.gov/node/37268/psn-pdf
December 16, 2011 - Prevention of wrong-site tooth extraction: clinical
guidelines.
December 16, 2011
Lee JS, Curley AW, Smith RA, et al. Prevention of wrong-site tooth extraction: clinical guidelines. J Oral
Maxillofac Surg. 2007;65(9):1793-9.
https://psnet.ahrq.gov/issue/prevention-wrong-site-tooth-extraction-clinical-guidelines
T…
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psnet.ahrq.gov/node/72862/psn-pdf
March 17, 2021 - Cutaneous Procedures Adverse Events Reporting
(CAPER).
March 17, 2021
The American Society for Dermatologic Surgery Association and the Northwestern University Department
of Dermatology.
https://psnet.ahrq.gov/issue/cutaneous-procedures-adverse-events-reporting-caper
Voluntary reporting systems collect adverse ev…
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psnet.ahrq.gov/node/72713/psn-pdf
February 03, 2021 - Patient/Family Crisis Hotline.
February 3, 2021
Sorry Works!
https://psnet.ahrq.gov/issue/patientfamily-crisis-hotline
Patients and families experiencing medical error may not always have access to the support needed to
navigate the system to inform improvements and receive appropriate restitution. This hotl…
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psnet.ahrq.gov/node/40899/psn-pdf
November 02, 2011 - Understanding the behaviour of newly qualified doctors in
acute care contexts.
November 2, 2011
Tallentire VR, Smith SE, Skinner J, et al. Understanding the behaviour of newly qualified doctors in acute
care contexts. Med Educ. 2011;45(10):995-1005. doi:10.1111/j.1365-2923.2011.04024.x.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45568/psn-pdf
October 19, 2016 - Pediatric Quality and Safety.
October 19, 2016
Brilli RJ, McClead RE Jr, eds. Alphen aan den Rijn, The Netherlands: Wolters Kluwer. ISSN: 2472-0054.
https://psnet.ahrq.gov/issue/pediatric-quality-and-safety
Care delivery for children presents unique safety challenges. This monthly, open-access journal focuses on
e…
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psnet.ahrq.gov/node/40952/psn-pdf
December 07, 2011 - Hospital quality and patient safety competencies:
development, description, and recommendations for use.
December 7, 2011
O'Leary KJ, Afsar-Manesh N, Budnitz T, et al. Hospital quality and patient safety competencies:
Development, description, and recommendations for use. J Hosp Med. 2011;6(9). doi:10.1002/jhm.937.…
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psnet.ahrq.gov/node/73099/psn-pdf
March 31, 2021 - Supporting nurses as essential partners in diagnosis.
March 31, 2021
Carr S. ImproveDx. March 2021:8(2)
https://psnet.ahrq.gov/issue/supporting-nurses-essential-partners-diagnosis
Effective diagnosis is enhanced through multidisciplinary team-based efforts. This newsletter article
outlines opportunities inhe…
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals
6. How do we sustain the redesigned prevention practices?
Previous Page Next Page
Table of Contents
Preventing Pressure Ulcers in Hospitals
Overview
Key Subject Area Index
1. Are we ready for this change?
2. How will we manage change?
3. What are the…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
AHRQ Safety Program for Perinatal Care
Patient and Family Engagement for Perinatal Safety
AHRQ Publication No. 17-0003-6-EF
May 2017
1
Learning Objectives
2
AHRQ Safety Program for Perinatal Care
Patient & Fam…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Learning From Defects Tool - Example
ICU & Non-ICU
Problem statement: Healthcare organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that future patients will be harmed.
What is a defect? A defect is any cli…
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www.ahrq.gov/hai/cauti-tools/ena-slides/part1a.html
October 01, 2015 - The Emergency Nurses Association Presents CAUTI Slides and Transcript
Part One: Traditional Practice and Recommendations for Change (continued)
Previous Page Next Page
Table of Contents
The Emergency Nurses Association Presents CAUTI Slides and Transcript
Opening Materials: Attribution, Objectives…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra-16-p001-2-ef.pdf
April 01, 2016 - Measure: Developmental Screening Follow-up: Follow-up Referral After Positive Developmental Screen
Measure: Developmental Screening Follow-up:
Follow-up Referral After Positive
Developmental Screen
Measure Developer: Pediatric Measurement Center of Excellence (PMCoE)
Numerator Denominator Exclusions Data Source(s…