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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - This was a valuable and efficient approach to supporting a global workforce that had very high needs
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - formulations to improve safe use, dispensing, and storage of opioids; take-back programs that facilitate the efficient
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - The rallying point is the positive effect of effective and efficient collaboration and communication
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - The rallying point is the positive effect of effective and efficient collaboration and communication
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - outcomes. 3,4
Operational Concerns
Given that the nature of EMS is to provide emergent services, efficient
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - improvement in quality and set forward the basic framework for quality: safe, timely, effective, equitable, efficient
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - improvement in quality and set forward the basic framework for quality: safe, timely, effective, equitable, efficient
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - hospitals use reports to improve safety.( 6-7 ) Some hospitals have reduced these barriers by developing efficient
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - SPOTLIGHT CASE
Duty to Disclose Someone Else's Error?
Citation Text:
Gallagher TH. Duty to Disclose Someone Else's Error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
Also Read the Essay
View more articles from the same authors.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…