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psnet.ahrq.gov/issue/impact-comprehensive-patient-safety-strategy-obstetric-adverse-events
October 20, 2014 - Study
Impact of a comprehensive patient safety strategy on obstetric adverse events.
Citation Text:
Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-8. doi:10.1016/j.ajog.2009.0…
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psnet.ahrq.gov/issue/towards-diagnostic-excellence-academic-ward-teams-building-conceptual-model-team-dynamics
August 20, 2018 - Study
Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.
Citation Text:
Choi JJ, Rosen MA, Shapiro MF, et al. Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in t…
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psnet.ahrq.gov/issue/development-and-interrater-agreement-novel-classification-system-combining-medical-and
September 20, 2011 - Study
Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.
Citation Text:
Stone A, Jiang ST, Stahl MC, et al. Development and interrater agreement of a novel classification system combining medical and surgical adve…
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - The palliative care team continued to advocate for the patient by establishing a plan of care with the
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psnet.ahrq.gov/issue/evaluating-efforts-optimize-teamstepps-implementation-surgical-and-pediatric-intensive-care
April 12, 2014 - Study
Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.
Citation Text:
Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patie…
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psnet.ahrq.gov/issue/preventing-medication-errors-long-term-care-results-and-evaluation-large-scale-web-based
June 15, 2011 - Study
Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.
Citation Text:
Pierson S, Hansen RA, Greene SB, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error…
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psnet.ahrq.gov/issue/attitudes-and-barriers-medical-emergency-team-system-tertiary-paediatric-hospital
April 11, 2011 - Study
Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.
Citation Text:
Azzopardi P, Kinney S, Moulden A, et al. Attitudes and barriers to a Medical Emergency Team system at a tertiary paediatric hospital. Resuscitation. 2011;82(2):167-74. doi:…
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psnet.ahrq.gov/issue/avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective
November 12, 2014 - Study
Classic
Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis.
Citation Text:
Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association wit…
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psnet.ahrq.gov/issue/diagnostic-concordance-among-pathologists-interpreting-breast-biopsy-specimens
July 13, 2016 - Study
Classic
Diagnostic concordance among pathologists interpreting breast biopsy specimens.
Citation Text:
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122-1132. do…
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psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence
March 01, 2011 - Study
High reliability in a safety net hospital leading to operational excellence.
Citation Text:
Didion L, Whitfield C, Bishop P, et al. High reliability in a safety net hospital leading to operational excellence. J Patient Saf. 2024;20(5):375-380. doi:10.1097/pts.0000000000001236.
Co…
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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/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/return-investment-vendor-computerized-physician-order-entry-four-community-hospitals
November 26, 2014 - Study
Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support.
Citation Text:
Zimlichman E, Keohane C, Franz C, et al. Return on investment for vendor computerized physician order entry in four community hospita…
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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/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/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/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/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - Vision and Leadership
Setting strategic goals and establishing values and a focus on safety at the
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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.” …
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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