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psnet.ahrq.gov/node/39781/psn-pdf
November 23, 2016 - Advancing Effective Communication, Cultural
Competence, and Patient- and Family-Centered Care: A
Roadmap for Hospitals.
November 23, 2016
Oakbrook Terrace, IL: The Joint Commission; 2010.
https://psnet.ahrq.gov/issue/advancing-effective-communication-cultural-competence-and-patient-and-
family-centered-care
This…
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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/45226/psn-pdf
January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in
Health Care.
January 4, 2017
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care
Research is increasingly focusing on diagnostic errors and strategies to reduc…
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psnet.ahrq.gov/node/39609/psn-pdf
June 27, 2010 - Identification and Prevention of Common Adverse Drug
Events in the Intensive Care Unit.
June 27, 2010
Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.
https://psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit
This supplem…
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psnet.ahrq.gov/node/50715/psn-pdf
December 04, 2019 - Quality and Safety of Healthcare in Switzerland.
December 4, 2019
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public
Health; 2019.
https://psnet.ahrq.gov/issue/quality-and-safety-healthcare-switzerland
Patient safety is a goal for countries worldwide. This report …
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psnet.ahrq.gov/node/865819/psn-pdf
May 08, 2024 - Focus on HARM (Harmonizing Accountability in
Reporting and Monitoring).
May 8, 2024
National Quality Forum.
https://psnet.ahrq.gov/issue/focus-harm-harmonizing-accountability-reporting-and-monitoring
Strong incident reporting systems are a foundational component for understanding preventable health care
error. Th…
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psnet.ahrq.gov/node/42330/psn-pdf
June 12, 2013 - Creating a culture of safety in the emergency department:
the value of teamwork training.
June 12, 2013
Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of
teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e31828958cd.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/39324/psn-pdf
April 07, 2010 - Redesigning a morbidity and mortality program in a
university-affiliated pediatric anesthesia department.
April 7, 2010
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated
pediatric anesthesia department. Jt Comm J Qual Patient Saf. 2010;36(3):117-125.
https://psn…
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psnet.ahrq.gov/node/38452/psn-pdf
December 30, 2014 - The safety of intravenous drug delivery systems: update
on current issues since the 1999 Consensus Development
Conference.
December 30, 2014
Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.
https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-
consensus-develo…
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psnet.ahrq.gov/node/42521/psn-pdf
August 21, 2013 - Why your TeamSTEPPS program may not be working.
August 21, 2013
Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs.
2012;9(8). doi:10.1016/j.ecns.2012.03.007.
https://psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
This commentary explores barriers to implementi…
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psnet.ahrq.gov/node/42765/psn-pdf
November 30, 2016 - Advancing Patient Safety Implementation Through Safe
Medication Use Research (R18).
November 30, 2016
Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.
https://psnet.ahrq.gov/issue/advancing-patient-safety-implementation-through-safe-medication-use-
research-r18
This funding program will suppo…
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psnet.ahrq.gov/node/39384/psn-pdf
March 24, 2010 - Keeping safety a priority in home care and hospice: one
agency's journey.
March 24, 2010
Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse.
2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939.
https://psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-ho…
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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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psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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psnet.ahrq.gov/node/44720/psn-pdf
December 16, 2015 - The persistent problem of diagnostic error.
December 16, 2015
Lundberg GD. Medscape. December 1, 2015.
https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a
patient safety problem, this commentary out…
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psnet.ahrq.gov/node/46708/psn-pdf
February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship
Program.
February 8, 2023
Food and Drug Administration, Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program
This fellowship program provides clinicians with learning opportunities at the Institute…
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psnet.ahrq.gov/node/43920/psn-pdf
July 10, 2018 - Master of Science in Medical and Healthcare Simulation.
July 10, 2018
Drexel University College of Medicine.
https://psnet.ahrq.gov/issue/master-science-medical-and-healthcare-simulation
Simulation training enables learning from mistakes without the potential for patient harm. This
multidisciplinary degree program…
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psnet.ahrq.gov/node/42256/psn-pdf
May 10, 2013 - Rapid response systems: should we still question their
implementation?
May 10, 2013
Winters BD, Pronovost P. Rapid response systems: should we still question their implementation? J Hosp
Med. 2013;8(5):278-81. doi:10.1002/jhm.2050.
https://psnet.ahrq.gov/issue/rapid-response-systems-should-we-still-question-their-…
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psnet.ahrq.gov/node/41992/psn-pdf
May 23, 2013 - Errors as allies: error management training in health
professions education.
May 23, 2013
King A, Holder MG, Ahmed RA. Errors as allies: error management training in health professions
education. BMJ Qual Saf. 2013;22(6):516-9. doi:10.1136/bmjqs-2012-000945.
https://psnet.ahrq.gov/issue/errors-allies-error-managem…
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www.ahrq.gov/cpi/about/impact/index.html
April 01, 2017 - AHRQ Works: Building Bridges Between Research and Practice
Accelerating learning and innovation in health care delivery is what AHRQ does—every day. AHRQ tools take the "what" and translate it into the “how” by providing research-backed, practical tools that doctors and nurses can use to improve care.
Thi…