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psnet.ahrq.gov/node/40717/psn-pdf
August 24, 2011 - Revealing their medical errors: why three doctors went
public.
August 24, 2011
O'Reilly KB.
https://psnet.ahrq.gov/issue/revealing-their-medical-errors-why-three-doctors-went-public
This news article reports on health care providers who have publicly revealed direct involvement in cases
of medical errors, with a …
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case November 2006
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Source and Credits
This presentation is based on the November 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is…
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm
Fatigue
May 1, 2016
Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet].
2016.
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
Perspective
Alarm fatigue occurs whe…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
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psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
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psnet.ahrq.gov/node/848378/psn-pdf
May 04, 2023 - Ensuring competency and safety when onboarding newly
hired professional staff.
May 3, 2023
ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.
https://psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-
staff
Psychological sa…
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psnet.ahrq.gov/node/73312/psn-pdf
May 26, 2021 - Healthcare professionals experience of psychological
safety, voice, and silence.
May 26, 2021
O'Donovan R, De Brún A, McAuliffe E. Healthcare professionals experience of psychological safety, voice,
and silence. Front Psychol. 2021;12:626689. doi:10.3389/fpsyg.2021.626689.
https://psnet.ahrq.gov/issue/healthcare-p…
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psnet.ahrq.gov/issue/encouraging-employees-speak-prevent-infections-opportunities-leverage-quality-improvement-and
January 23, 2017 - Study
Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.
Citation Text:
Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …
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psnet.ahrq.gov/node/40009/psn-pdf
November 26, 2014 - Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based
learning system.
November 26, 2014
Wittich CM, Lopez-Jimenez F, Decker LK, et al. Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based learning system. J …
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - Strategies to Improve Patient Safety: Final Report to
Congress Required by the Patient Safety and Quality
Improvement Act of 2005.
December 15, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-
0009.
https://psnet.ahrq.gov/issue/strategies-improve-patient-safe…
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psnet.ahrq.gov/node/45069/psn-pdf
June 01, 2016 - The effects of power, leadership and psychological safety
on resident event reporting.
June 1, 2016
Appelbaum NP, Dow A, Mazmanian PE, et al. The effects of power, leadership and psychological safety on
resident event reporting. Med Edu. 2016;50(3):343-350. doi:10.1111/medu.12947.
https://psnet.ahrq.gov/issue/effe…
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psnet.ahrq.gov/node/39195/psn-pdf
January 28, 2010 - Lack of patient knowledge regarding hospital
medications.
January 28, 2010
Lack of patient knowledge regarding hospital medications.
https://psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
The Joint Commission requires that hospitals encourage patients' involvement in their own safety as…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/node/36378/psn-pdf
October 28, 2010 - Teaching but not learning: how medical residency
programs handle errors.
October 28, 2010
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J
Organ Behav. 2006;27(7). doi:10.1002/job.395.
https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-pr…