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psnet.ahrq.gov/node/44547/psn-pdf
November 25, 2015 - Monitoring patient safety in primary care: an exploratory
study using in-depth semistructured interviews.
November 25, 2015
Samra R, Bottle A, Aylin PP. Monitoring patient safety in primary care: an exploratory study using in-depth
semistructured interviews. BMJ Open. 2015;5(9):e008128. doi:10.1136/bmjopen-2015-008…
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psnet.ahrq.gov/node/60929/psn-pdf
September 16, 2020 - Safer Together: A National Action Plan to Advance Patient
Safety.
September 16, 2020
Boston, MA: Institute for Healthcare Improvement: September 2020.
https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety
This National Action Plan developed by the National Steering Committee for Pati…
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psnet.ahrq.gov/taxonomy/term/3504
June 24, 2025 - Workaround
From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and acti…
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psnet.ahrq.gov/node/43108/psn-pdf
September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report.
September 28, 2023
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
This annual report summarizes never events in Maryland hospit…
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psnet.ahrq.gov/node/45024/psn-pdf
December 19, 2017 - Leveraging a redesigned morbidity and mortality
conference that incorporates the clinical and educational
missions of improving quality and patient safety.
December 19, 2017
Tad-Y DB, Pierce RG, Pell JM, et al. Leveraging a Redesigned Morbidity and Mortality Conference That
Incorporates the Clinical and Educationa…
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psnet.ahrq.gov/node/836918/psn-pdf
April 13, 2022 - How to scale up quality and safety program with the home
care accreditation.
April 13, 2022
Brunelli L, Cristofori V, Battistella C, et al. How to scale up quality and safety program with the home care
accreditation. Int J Integr Care. 2022;22(1):19. doi:10.5334/ijic.5698.
https://psnet.ahrq.gov/issue/how-scale-qu…
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psnet.ahrq.gov/node/44218/psn-pdf
July 01, 2016 - The Armstrong Institute: an academic institute for patient
safety and quality improvement, research, training, and
practice.
July 1, 2016
Pronovost P, Holzmueller CG, Molello NE, et al. The Armstrong Institute: An Academic Institute for Patient
Safety and Quality Improvement, Research, Training, and Practice. Acad…
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psnet.ahrq.gov/node/45570/psn-pdf
December 07, 2016 - Getting the Board on Board: What Your Board Needs to
Know About Quality and Safety, Third Edition.
December 7, 2016
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety-
third-edition
Engaging hospital lead…
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psnet.ahrq.gov/node/37790/psn-pdf
April 11, 2011 - Adolescent use of insulin and patient-controlled
analgesia pump technology: a 10-year Food and Drug
Administration retrospective study of adverse events.
April 11, 2011
Cope JU, Morrison AE, Samuels-Reid J. Adolescent use of insulin and patient-controlled analgesia pump
technology: a 10-year Food and Drug Administ…
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets
November 1, 2016
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
The Case
A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/node/47590/psn-pdf
February 20, 2019 - Explaining organisational responses to a board-level
quality improvement intervention: findings from an
evaluation in six providers in the English National Health
Service.
February 20, 2019
Jones L, Pomeroy L, Robert G, et al. Explaining organisational responses to a board-level quality
improvement intervention: …
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psnet.ahrq.gov/node/866119/psn-pdf
June 12, 2024 - Artificial intelligence in the provision of health care: an
American College of Physicians policy position paper.
June 12, 2024
Daneshvar N, Pandita D, Erickson S, et al. Artificial Intelligence in the Provision of Health Care: An
American College of Physicians Policy Position Paper. Ann Intern Med. 2024;177(7):964…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - The federal government and many of its national initiatives, like the Center for
Medicare and Medicaid
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets
Citation Text:
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/node/44965/psn-pdf
February 15, 2017 - Identification and Prioritization of Health IT Patient Safety
Measures.
February 15, 2017
Washington, DC: National Quality Forum; February 2016.
https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
Health information technology (IT) has transformed health care and improv…
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Patient groups, clinicians and healthcare professionals
agree—all test results need to be seen, understood and
followed up.
December 19, 2018
Dahm MR, Georgiou A, Herkes R, et al. Patient groups, clinicians and healthcare professionals agree - all
test results need to be seen, understood and followed up. Diagnosis…
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psnet.ahrq.gov/node/39691/psn-pdf
January 22, 2014 - Responsibility for quality improvement and patient safety:
hospital board and medical staff leadership challenges.
January 22, 2014
Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital
board and medical staff leadership challenges. Chest. 2010;138(1):171-8. doi:10…
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psnet.ahrq.gov/node/72752/psn-pdf
February 17, 2021 - Why do healthcare professionals fail to escalate as per
the early warning system (EWS) protocol? A qualitative
evidence synthesis of the barriers and facilitators of
escalation.
February 17, 2021
O’Neill SM, Clyne B, Bell M, et al. Why do healthcare professionals fail to escalate as per the early warning
system (…