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psnet.ahrq.gov/node/852804/psn-pdf
August 23, 2023 - Five new ways to advance diagnostic safety in your
clinical practice.
August 23, 2023
Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.
https://psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
Diagnostic errors are common in the ambulatory environment.…
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psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
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psnet.ahrq.gov/node/46367/psn-pdf
August 30, 2017 - Why are so many women being misdiagnosed?
August 30, 2017
Mickle K. Glamour. August 11, 2017.
https://psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed
Implicit bias and differences in communication style can affect patient care. This magazine article reports
on factors that contribute to misdiagnosis …
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psnet.ahrq.gov/node/48041/psn-pdf
July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a
meta-analysis.
July 10, 2019
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol.
2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375.
https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
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psnet.ahrq.gov/node/40199/psn-pdf
March 03, 2011 - Perspective: malpractice in an academic medical center: a
frequently overlooked aspect of professionalism
education.
March 3, 2011
Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a
frequently overlooked aspect of professionalism education. Acad Med. 2011;86(3):365-8.…
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psnet.ahrq.gov/node/44718/psn-pdf
November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient
Safety.
November 25, 2015
Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto;
2015.
https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
The 2004 Canadian Adverse Events Study helpe…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/references/index.html
April 01, 2013 - References
Tobacco reference materials and guides for health care providers
General References for Guideline | General References [ - 191.43 KB]
General References for the 2008 Update
References for Studies in Meta-analyses | Studies in Meta-analyses - References [ - 230.99 KB]
This Clinical P…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/staffsafetyassess.doc
June 02, 2025 - Staff Safety Assessment
Purpose of this form: This form is designed to tap into your experience at the front line of patient care to determine what risks are present in your unit that have jeopardized or could jeopardize patient safety.
Who should us this tool? Health care providers.
How to complete this form: Provi…
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psnet.ahrq.gov/node/46636/psn-pdf
January 24, 2018 - Drug shortages continue to compromise patient care.
January 24, 2018
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…
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psnet.ahrq.gov/node/848825/psn-pdf
May 10, 2023 - Laura Levis' death outside ER has changed hospital
signage, lighting in Mass.
May 10, 2023
Mullins L, Menard F. WBUR. April 27, 2023.
https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass
Incomplete information and building design problems can reduce access to care an…
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psnet.ahrq.gov/node/44442/psn-pdf
August 26, 2015 - How your hospital can make you sick.
August 26, 2015
Consumer Reports. July 29, 2015.
https://psnet.ahrq.gov/issue/how-your-hospital-can-make-you-sick
This news article reports on health care–associated infections, particularly Clostridium difficile and
methicillin-resistant Staphylococcus aureus, discusses ways h…
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psnet.ahrq.gov/node/44243/psn-pdf
November 09, 2015 - Concept analysis: wrong-site surgery.
November 9, 2015
Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6.
doi:10.1016/j.aorn.2015.03.012.
https://psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. Th…
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psnet.ahrq.gov/node/844771/psn-pdf
September 11, 2019 - Raising and responding to frontline concerns in
healthcare.
September 11, 2019
Mannion R, Davies H. Raising and responding to frontline concerns in healthcare. BMJ. 2019;366:l4944.
doi:10.1136/bmj.l4944.
https://psnet.ahrq.gov/issue/raising-and-responding-frontline-concerns-healthcare
Psychological safety empower…
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psnet.ahrq.gov/node/41069/psn-pdf
February 21, 2012 - Using the opportunity estimator tool to improve
engagement in a quality and safety intervention.
February 21, 2012
Duval-Arnould J, Mathews SC, Weeks K, et al. Using the Opportunity Estimator tool to improve
engagement in a quality and safety intervention. Jt Comm J Qual Patient Saf. 2012;38(1):41-47, 1.
https://p…
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psnet.ahrq.gov/node/43700/psn-pdf
November 19, 2014 - Appropriate use of medical interpreters.
November 19, 2014
Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-80.
https://psnet.ahrq.gov/issue/appropriate-use-medical-interpreters
Language barriers between patients and providers can contribute to misunderstandings and lead…
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psnet.ahrq.gov/node/39251/psn-pdf
September 24, 2016 - No interruptions please: impact of a no interruption zone
on medication safety in intensive care units.
September 24, 2016
Anthony K, Wiencek C, Bauer C, et al. No interruptions please: impact of a No Interruption Zone on
medication safety in intensive care units. Crit Care Nurse. 2010;30(3):21-9. doi:10.4037/ccn20…
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psnet.ahrq.gov/node/45607/psn-pdf
July 14, 2019 - Duke Center for Healthcare Safety and Quality.
July 14, 2019
Duke University Health System.
https://psnet.ahrq.gov/issue/duke-center-healthcare-safety-and-quality
This website provides resources to help individuals, hospitals, outpatient practices, and others improve
quality and patient safety. The materials inclu…
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psnet.ahrq.gov/node/42555/psn-pdf
January 15, 2014 - Patient Safety: Committing to Learn and Acting to
Improve.
January 15, 2014
Twigg D, Attree M, eds. Nurse Educ Today. 2014;34(2):159-284.
https://psnet.ahrq.gov/issue/patient-safety-committing-learn-and-acting-improve
This special issue highlights research exploring educational, learning, and leadersh…
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psnet.ahrq.gov/node/845351/psn-pdf
March 01, 2023 - Access to Clinical Information at the Bedside.
March 1, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; February 2023.
https://psnet.ahrq.gov/issue/access-clinical-information-bedside
Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety.
This rep…
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psnet.ahrq.gov/node/47268/psn-pdf
May 11, 2019 - Measuring shared mental models in healthcare.
May 11, 2019
Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219.
https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare
Shared mental models are an important element of team collaboration. This review explores the current…