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psnet.ahrq.gov/issue/responding-clinicians-who-fail-follow-patient-safety-practices-perceptions-physicians-nurses
February 24, 2011 - Study
Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients.
Citation Text:
Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nu…
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psnet.ahrq.gov/issue/effects-interdisciplinary-team-care-interventions-general-medical-wards-systematic-review
April 24, 2018 - Review
Classic
Effects of interdisciplinary team care interventions on general medical wards: a systematic review.
Citation Text:
Pannick S, Davis R, Ashrafian H, et al. Effects of Interdisciplinary Team Care Interventions on General Medical Wards: A Systematic …
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psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety
March 13, 2013 - Commentary
Classic
Balancing "no blame" with accountability in patient safety.
Citation Text:
Wachter R, Pronovost P. Balancing "no blame" with accountability in patient safety. New Engl J Med. 2009;361(14):1401-1406. doi:10.1056/NEJMsb0903885.
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psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
November 21, 2011 - Study
Incorrect surgical procedures within and outside of the operating room.
Citation Text:
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126.
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psnet.ahrq.gov/issue/comprehensive-obstetric-patient-safety-program-reduces-liability-claims-and-payments
June 22, 2017 - Study
A comprehensive obstetric patient safety program reduces liability claims and payments.
Citation Text:
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.10…
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psnet.ahrq.gov/issue/culture-and-behaviour-english-national-health-service-overview-lessons-large-multimethod
May 01, 2015 - Study
Classic
Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.
Citation Text:
Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of les…
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psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2016-user-comparative-database-report
November 23, 2016 - Book/Report
Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report.
Citation Text:
Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report. Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthca…
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psnet.ahrq.gov/issue/sustaining-reliability-accountability-measures-johns-hopkins-hospital
January 19, 2014 - Study
Sustaining reliability on accountability measures at the Johns Hopkins Hospital.
Citation Text:
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
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psnet.ahrq.gov/issue/changes-medical-errors-after-implementation-handoff-program
April 24, 2018 - Study
Classic
Changes in medical errors after implementation of a handoff program.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803-1812. doi:10.105…
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psnet.ahrq.gov/issue/leadership-safety-climate-and-continuous-quality-improvement-impact-process-quality-and
May 24, 2006 - Study
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.
Citation Text:
McFadden KL, Stock GN, Gowen CR. Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. Health Care Ma…
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psnet.ahrq.gov/issue/i-pass-handoff-program-use-campaign-effect-transformational-change
April 24, 2018 - Study
I-PASS handoff program: use of a campaign to effect transformational change.
Citation Text:
Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088.
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psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors
April 12, 2017 - Study
Automated detection of wrong-drug prescribing errors.
Citation Text:
Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf. 2019;28(11):908-915. doi:10.1136/bmjqs-2019-009420.
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psnet.ahrq.gov/issue/surgical-residents-work-hours-and-well-being-year-2-first-trial
March 15, 2017 - Study
Surgical residents' work hours and well-being in year 2 of the FIRST trial.
Citation Text:
Dahlke AR, Quinn CM, Chung JW, et al. Surgical Residents' Work Hours and Well-Being in Year 2 of the FIRST Trial. New Engl J Med. 2017;377(2):192-194. doi:10.1056/NEJMc1703812.
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psnet.ahrq.gov/issue/utilising-improvement-science-methods-optimise-medication-reconciliation
July 24, 2017 - Study
Utilising improvement science methods to optimise medication reconciliation.
Citation Text:
White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimise medication reconciliation. BMJ Qual Saf. 2011;20(4):372-80. doi:10.1136/bmjqs.2010.047845.
Co…
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Citation Text:
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …
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psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room-follow-report
April 30, 2014 - Study
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Citation Text:
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146(11):1235-9. doi:10.1001…
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psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
June 14, 2017 - Review
Classic
Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.
Citation Text:
Winters BD, Bharmal A, Wilson RF, et…
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psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
November 01, 2019 - University of California, Davis, Health CME/CEU Information
WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit. Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …