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psnet.ahrq.gov/node/40431/psn-pdf
May 11, 2011 - A Call for Change: The 2011 Commonwealth Fund Survey
of Public Views of the U.S. Health System.
May 11, 2011
Stremikis K, Schoen C, Fryer AK. Issue Brief. Washington DC: The Commonwealth Fund; April 2011.
https://psnet.ahrq.gov/issue/call-change-2011-commonwealth-fund-survey-public-views-us-health-system
This publ…
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psnet.ahrq.gov/node/43674/psn-pdf
November 12, 2014 - Living with cancer: not talking about medical mistakes.
November 12, 2014
Gubar S.
https://psnet.ahrq.gov/issue/living-cancer-not-talking-about-medical-mistakes
This newspaper article describes how surgical complications, health care–associated infections, and
ineffective patient–provider communication contributed…
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psnet.ahrq.gov/node/36908/psn-pdf
January 05, 2017 - Benefits of a rapid response system at a community
hospital.
January 5, 2017
Gessner P. Benefits of a Rapid Response System at a Community Hospital. The Joint Commission Journal
on Quality and Patient Safety. 2016;33(6). doi:10.1016/s1553-7250(07)33040-7.
https://psnet.ahrq.gov/issue/benefits-rapid-response-system…
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psnet.ahrq.gov/node/50787/psn-pdf
January 08, 2020 - Q3 Health Innovation Partners.
January 8, 2020
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem
Association of Pennsylvania.
https://psnet.ahrq.gov/issue/q3-health-innovation-partners
Local efforts that draw from the experience of its leaders serve an important role …
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psnet.ahrq.gov/node/43094/psn-pdf
May 28, 2015 - Implementing human factors in clinical practice.
May 28, 2015
Timmons S, Baxendale B, Buttery A, et al. Implementing human factors in clinical practice. Emerg Med J.
2015;32(5):368-72. doi:10.1136/emermed-2013-203203.
https://psnet.ahrq.gov/issue/implementing-human-factors-clinical-practice
Human factors approache…
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psnet.ahrq.gov/node/40959/psn-pdf
November 30, 2011 - Error detection and recovery in dialysis nursing.
November 30, 2011
Wilkinson WE, Cauble LA, Patel VL. Error detection and recovery in dialysis nursing. J Patient Saf.
2011;7(4):213-23. doi:10.1097/PTS.0b013e3182388d20.
https://psnet.ahrq.gov/issue/error-detection-and-recovery-dialysis-nursing
This study found tha…
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psnet.ahrq.gov/node/72642/psn-pdf
January 13, 2021 - Patient Safety
January 13, 2021
Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.
https://psnet.ahrq.gov/issue/patient-safety-22
Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special
issue cover topics such as human factors, checklists, teamwork, and telem…
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psnet.ahrq.gov/node/41374/psn-pdf
September 24, 2016 - Interruptions and miscommunications in surgery: an
observational study.
September 24, 2016
Gillespie BM, Chaboyer W, Fairweather N. Interruptions and miscommunications in surgery: an
observational study. AORN J. 2012;95(5):576-90. doi:10.1016/j.aorn.2012.02.012.
https://psnet.ahrq.gov/issue/interruptions-and-misco…
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psnet.ahrq.gov/node/37599/psn-pdf
January 01, 2009 - Improving process while changing practice: FMEA and
medication administration.
March 12, 2008
Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2).
doi:10.1097/01.numa.0000310533.54708.38.
https://psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and…
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psnet.ahrq.gov/node/43107/psn-pdf
March 14, 2016 - Researchers' roles in patient safety improvement.
March 14, 2016
Pietikäinen E, Reiman T, Heikkilä J, et al. Researchers' Roles in Patient Safety Improvement. J Patient Saf.
2016;12(1):25-33. doi:10.1097/PTS.0000000000000096.
https://psnet.ahrq.gov/issue/researchers-roles-patient-safety-improvement
Through a self-…
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psnet.ahrq.gov/node/42340/psn-pdf
June 05, 2013 - Medical errors are hard for doctors to admit, but it's wise
to apologize to patients.
June 5, 2013
Jain M.
https://psnet.ahrq.gov/issue/medical-errors-are-hard-doctors-admit-its-wise-apologize-patients
This newspaper article reports on disclosure and apology for medical errors, recounts a physician's
personal exp…
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psnet.ahrq.gov/node/36172/psn-pdf
August 09, 2006 - The Patient Safety Group.
August 9, 2006
https://psnet.ahrq.gov/issue/patient-safety-group
Development of The Patient Safety Group was motivated by the death of a young girl named Josie King.
The King family responded to their personal experience from medical errors by making a commitment to
improve and advance sa…
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psnet.ahrq.gov/node/50668/psn-pdf
November 13, 2019 - Case Study Webinar Series on Clinician Burnout: The
Ohio State University
November 13, 2019
NAM Action Collaborative on Clinician Well-Being and Resilience. Case Study Webinar Series on Clinician
Burnout: The Ohio State University. National Academies of Medicine.
https://psnet.ahrq.gov/issue/case-study-webinar-ser…
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psnet.ahrq.gov/node/35034/psn-pdf
November 05, 2015 - Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care. Second edition.
November 5, 2015
Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute for Healthcare Improvement; 2008.
https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-car…
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psnet.ahrq.gov/node/35408/psn-pdf
August 05, 2009 - Factors influencing preceptors' responses to medical
errors: a factorial survey.
August 5, 2009
Mazor KM, Fischer M, Haley H-L, et al. Factors influencing preceptors' responses to medical errors: a
factorial survey. Acad Med. 2005;80(10 Suppl):S88-92.
https://psnet.ahrq.gov/issue/factors-influencing-preceptors-res…
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psnet.ahrq.gov/node/38195/psn-pdf
January 02, 2017 - University of Michigan: quality and safety in an academic
medical center.
January 2, 2017
Strong DL, Kin JM, Kratochwill EW, et al. University of Michigan: quality and safety in an academic medical
center. Jt Comm J Qual Patient Saf. 2008;34(11):671-7.
https://psnet.ahrq.gov/issue/university-michigan-quality-and-s…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …