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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
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Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/curated-library/organizational-learning
April 17, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace
Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD
| October 31, 2023
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Jones CB, Sousane Z…
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psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
March 15, 2016 - Study
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
Citation Text:
Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Reports of the prevalence and incidence of these conditions vary; one study estimates that roughly 9% … The lack of reporting by new mothers can result in inaccurate prevalence estimates and hinder efforts
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33588/psn-pdf
March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors
and Adverse Events
March 15, 2025
Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
PSNet primers are regu…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - Reliable estimates of the frequency of this kind of adverse event are not available.
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Yet, current estimates suggest that 10% to12% of hospitalized patients are harmed during their care
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Bates DW, Lee M, Mossburg…
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Thus, precise estimates of the number of patients who are injured as a result of unsafe medical care
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - One analytic model estimates costs of $1.1-$1.4 million per RFO event prevented.( 12 ) Looking to the
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Organizational Learning
Curated Library
Foundations
Organizational learning: health care leaders need to design structures and processes that enhance
collective learning.
Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35.
This comment…
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Ambulatory Care Safety
Citation Text:
Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - Diagnostic Errors Diagnostic errors are common, estimated at around 5.7% in ED settings , with some estimates
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - psnet.ahrq.gov//#18
Diagnostic errors are common, estimated at around 5.7% in ED settings, with some estimates
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - SPOTLIGHT CASE
Anemia and Delayed Colon Cancer Diagnosis
Citation Text:
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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