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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Errors happen in the ambulatory setting, in the home care setting, and in other facility settings.
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - Errors happen in the ambulatory setting, in the home care setting, and in other facility settings.
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psnet.ahrq.gov/node/842779/psn-pdf
January 12, 2011 - Resilience Engineering in Practice: a Guidebook.
January 12, 2011
Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN:
9781472420749
https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook
Safety-critical industries rely on organizational aptitude to respond to disr…
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - around value and maybe even one in which pay is predicated on measureable value, do different things happen
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - some tension between the acts of research in improvement and the operational work to make improvement happen
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - pages long) was that no one was going to read a document that lengthy to make a decision that needed to happen
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - some tension between the acts of research in improvement and the operational work to make improvement happen
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - health care professionals, are going to be, and what will be the Agency's role in making these changes happen
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psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - A framework for assessing reasoning about controversial
end-of-life clinical decisions.
December 14, 2022
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-
life clinical decisions. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - And stuff comes up in doctors' lives, they have to move and things happen. … Where does that tradeoff happen?
DM : This is an important point.
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - And stuff comes up in doctors' lives, they have to move and things happen. … Where does that tradeoff happen?
DM : This is an important point.
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/49502/psn-pdf
February 01, 2006 - Deciphering the Code
February 1, 2006
Goldstein MK. Deciphering the Code. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/deciphering-code
The Case
An 85-year-old man with advanced oxygen-dependent chronic obstructive pulmonary disease (COPD)
presented to the emergency department (ED) with increasing shortn…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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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…