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psnet.ahrq.gov/node/41272/psn-pdf
April 06, 2012 - Closed medical negligence claims can drive patient safety
and reduce litigation.
April 6, 2012
Pegalis SE, Bal S. Closed medical negligence claims can drive patient safety and reduce litigation. Clin
Orthop Relat Res. 2012;470(5):1398-404. doi:10.1007/s11999-012-2308-5.
https://psnet.ahrq.gov/issue/closed-medical-…
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psnet.ahrq.gov/node/60961/psn-pdf
September 30, 2020 - Identifying psychiatric diagnostic errors with the Safer Dx
Instrument.
September 30, 2020
Fletcher TL, Helm A, Vaghani V, et al. Identifying psychiatric diagnostic errors with the Safer Dx Instrument.
Int J Qual Health Care. 2020;32(6):405-411. doi:10.1093/intqhc/mzaa066.
https://psnet.ahrq.gov/issue/identifying-…
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psnet.ahrq.gov/node/48025/psn-pdf
June 19, 2019 - Accuracy of a popular online symptom checker for
ophthalmic diagnoses.
June 19, 2019
Shen C, Nguyen M, Gregor A, et al. Accuracy of a Popular Online Symptom Checker for Ophthalmic
Diagnoses. JAMA Ophthalmol. 2019;137(6):690-692. doi:10.1001/jamaophthalmol.2019.0571.
https://psnet.ahrq.gov/issue/accuracy-popular-on…
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psnet.ahrq.gov/node/38630/psn-pdf
May 13, 2009 - Seasoned surgeons assessed in a laparoscopic surgical
crisis.
May 13, 2009
Powers K, Rehrig ST, Schwaitzberg SD, et al. Seasoned surgeons assessed in a laparoscopic surgical
crisis. J Gastrointest Surg. 2009;13(5):994-1003. doi:10.1007/s11605-009-0802-1.
https://psnet.ahrq.gov/issue/seasoned-surgeons-assessed-lapa…
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psnet.ahrq.gov/node/47144/psn-pdf
June 13, 2018 - Canadian Anesthesia Incident Reporting System.
June 13, 2018
Canadian Anaesthesiologists Society.
https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website
provides a secure tool for submitting…
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psnet.ahrq.gov/node/60885/psn-pdf
September 02, 2020 - Becoming a High Reliability Organization.
September 2, 2020
VHA Forum. Summer 2020;1-12.
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization
High reliability attainment is a stated goal for health care organizations. This special issue covers
established initiatives at the United States Veterans He…
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psnet.ahrq.gov/node/35254/psn-pdf
April 06, 2011 - Adverse events and near miss reporting in the NHS.
April 6, 2011
Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care.
2005;14(4). doi:10.1136/qshc.2004.010553.
https://psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
This study evaluated the utility of a volu…
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psnet.ahrq.gov/node/42273/psn-pdf
December 29, 2014 - Assessing patient safety culture in hospitals across
countries.
December 29, 2014
Wagner C, Smits M, Sorra J, et al. Assessing patient safety culture in hospitals across countries. Int J Qual
Health Care. 2013;25(3):213-21. doi:10.1093/intqhc/mzt024.
https://psnet.ahrq.gov/issue/assessing-patient-safety-culture-ho…
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psnet.ahrq.gov/node/38812/psn-pdf
April 12, 2011 - Management of test results in family medicine offices.
April 12, 2011
Elder NC, McEwen TR, Flach JM, et al. Management of test results in family medicine offices. Ann Fam
Med. 2009;7(4):343-51. doi:10.1370/afm.961.
https://psnet.ahrq.gov/issue/management-test-results-family-medicine-offices
This study evaluated co…
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psnet.ahrq.gov/node/35302/psn-pdf
July 14, 2009 - Technology induced error and usability: the relationship
between usability problems and prescription errors when
using a handheld application.
July 14, 2009
Kushniruk AW, Triola MM, Borycki EM, et al. Technology induced error and usability: The relationship
between usability problems and prescription errors when u…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/43489/psn-pdf
September 03, 2014 - Did hospital engagement networks actually improve care?
September 3, 2014
Pronovost P, Jha AK. Did hospital engagement networks actually improve care? N Engl J Med.
2014;371(8):691-693. doi:10.1056/NEJMp1405800.
https://psnet.ahrq.gov/issue/did-hospital-engagement-networks-actually-improve-care
In this commentary,…
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psnet.ahrq.gov/node/35181/psn-pdf
June 23, 2009 - Communication during trauma resuscitation: do we know
what is happening?
June 23, 2009
Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is
happening? Injury. 2005;36(8):905-11.
https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…
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psnet.ahrq.gov/node/50553/psn-pdf
October 16, 2019 - Impact of an electronic health record transition on
chemotherapy error reporting
October 16, 2019
Hess E, Palmer SE, Stivers A, et al. Impact of an electronic health record transition on chemotherapy error
reporting. J Oncol Pharm Pract. 2019:1078155219870590. doi:10.1177/1078155219870590.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/41762/psn-pdf
May 03, 2017 - Improving the Measurement of Surgical Site Infection
Risk Stratification/Outcome Detection: Final Contract
Report.
May 3, 2017
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ
Publication No. 12-0046-EF.
https://psnet.ahrq.gov/issue/improving-measurement-surgical-si…
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psnet.ahrq.gov/node/36004/psn-pdf
March 28, 2011 - Opportunities for performance improvement in relation to
medication administration during pediatric stabilization.
March 28, 2011
Morgan N. Opportunities for performance improvement in relation to medication administration during
pediatric stabilization. Quality and Safety in Health Care. 2006;15(3). doi:10.1136/qs…
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psnet.ahrq.gov/node/38258/psn-pdf
April 14, 2011 - How often do physicians review medication charts on
ward rounds?
April 14, 2011
Looi KL, Black PN. How often do physicians review medication charts on ward rounds? BMC Clin
Pharmacol. 2008;8:9. doi:10.1186/1472-6904-8-9.
https://psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
Thi…
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psnet.ahrq.gov/node/39442/psn-pdf
March 23, 2011 - Adverse events in hospitals: the patient's point of view.
March 23, 2011
Guijarro M, Andrés JMA, Mira JJ, et al. Adverse events in hospitals: the patient's point of view. Qual Saf
Health Care. 2010;19(2):144-7. doi:10.1136/qshc.2007.025585.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-patients-point-view
…
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psnet.ahrq.gov/node/45169/psn-pdf
June 08, 2016 - High Reliability in Health Care.
June 8, 2016
Joint Commission Center for Transforming Healthcare.
https://psnet.ahrq.gov/issue/high-reliability-health-care
Development of high reliability remains an elusive goal for health care organizations. The Joint Commission
has also advocated for achieving high reliability …
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - What do you think AHRQ's role is in evaluating the ACA and informing decisions about its future?