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psnet.ahrq.gov/node/37406/psn-pdf
March 28, 2012 - Learning from preventable adverse events in health care
organizations: development of a multilevel model of
learning and propositions.
March 28, 2012
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care
organizations: development of a multilevel model of learning and propositi…
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psnet.ahrq.gov/node/44279/psn-pdf
August 26, 2015 - Leadership style and patient safety: implications for
nurse managers.
August 26, 2015
Merrill KC. Leadership style and patient safety: implications for nurse managers. J Nurs Adm.
2015;45(6):319-324. doi:10.1097/NNA.0000000000000207.
https://psnet.ahrq.gov/issue/leadership-style-and-patient-safety-implications-nur…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - Fortunately,
there was the foresight to establish the National Quality Forum because it's easier if
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psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
March 1, 2014
Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
Perspective
In 1999, the Institute of Medicine (IOM) released the To …
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/43699/psn-pdf
November 26, 2014 - Diagnosing overdiagnosis: conceptual challenges and
suggested solutions.
November 26, 2014
Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol.
2014;29(9):599-604. doi:10.1007/s10654-014-9920-5.
https://psnet.ahrq.gov/issue/diagnosing-overdiagnosis-conceptual-challen…
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psnet.ahrq.gov/node/42976/psn-pdf
May 29, 2014 - Quality and safety in pediatric hematology/oncology.
May 29, 2014
Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9.
doi:10.1002/pbc.24946.
https://psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology
Children with cancer are particularly vulner…
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psnet.ahrq.gov/node/44457/psn-pdf
September 29, 2017 - Hospitals slow to adopt patient apology policies.
September 29, 2017
Rice S. Hospitals slow to adopt patient apology policies. Modern healthcare. 2015;45(33):16, 29-30.
https://psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies
Communication-and-resolution approaches to medical errors have garnered …
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psnet.ahrq.gov/node/39015/psn-pdf
October 14, 2009 - Delays and errors in cardiopulmonary resuscitation and
defibrillation by pediatric residents during simulated
cardiopulmonary arrests.
October 14, 2009
Hunt EA, Vera K, Diener-West M, et al. Delays and errors in cardiopulmonary resuscitation and
defibrillation by pediatric residents during simulated cardiopulmonar…
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psnet.ahrq.gov/node/42774/psn-pdf
May 28, 2015 - Patient safety in plastic surgery: identifying areas for
quality improvement efforts.
May 28, 2015
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas
for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602.
doi:10.1097/SAP.0b013e318297791e.
https:…
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psnet.ahrq.gov/node/41965/psn-pdf
January 30, 2013 - Vital sign abnormalities, rapid response, and adverse
outcomes in hospitalized patients.
January 30, 2013
Fagan K, Sabel A, Mehler PS, et al. Vital sign abnormalities, rapid response, and adverse outcomes in
hospitalized patients. Am J Med Qual. 2012;27(6):480-6. doi:10.1177/1062860611436127.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/43084/psn-pdf
May 19, 2014 - How can the criminal law support the provision of quality
in healthcare?
May 19, 2014
Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf.
2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688.
https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…
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psnet.ahrq.gov/node/33962/psn-pdf
June 22, 2007 - Enacting the Washington state patient safety act requiring
hospital staffing plans for nursing services and
establishing recordkeeping and reporting requirements.
June 22, 2007
HB 1602. Washington State Legislature. 2003-2004.
https://psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hosp…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/40356/psn-pdf
May 26, 2011 - Clinicians' satisfaction with CPOE ease of use and effect
on clinicians' workflow, efficiency and medication safety.
May 26, 2011
Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on
clinicians' workflow, efficiency and medication safety. Int J Med Inform. 2011;80(5)…
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psnet.ahrq.gov/node/46212/psn-pdf
September 13, 2017 - Improving patient care through improved caregiver
support.
September 13, 2017
Headley M. Patient Saf Qual Healthc. August 21, 2017.
https://psnet.ahrq.gov/issue/improving-patient-care-through-improved-caregiver-support
Health care workers face high levels of stress and production pressures, which can contribute to…
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psnet.ahrq.gov/node/45051/psn-pdf
May 11, 2016 - Pediatric quality and safety: a nursing perspective.
May 11, 2016
Butler GA, Hupp DS. Pediatric Quality and Safety. Pediatr Clin North Am. 2016;63(2).
doi:10.1016/j.pcl.2015.11.005.
https://psnet.ahrq.gov/issue/pediatric-quality-and-safety-nursing-perspective
Nurses play a key role in ensuring safety, particularly…
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psnet.ahrq.gov/node/46630/psn-pdf
November 15, 2017 - Patient Safety in the Office-Based Practice Setting.
November 15, 2017
Philadelphia, PA: American College of Physicians; 2017.
https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy.
Th…
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - communication with the outpatient provider helps the admitting physician clarify the
treatment plan and establish
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…