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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - Code Status vs. Care Status
December 23, 2020
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/code-status-vs-care-status
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (AC…
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety?
Rebecca N. Warburton, PhD | April 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/node/43643/psn-pdf
November 04, 2014 - Out-of-hospital medication errors among young children
in the United States, 2002–2012.
November 4, 2014
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the
United States, 2002-2012. Pediatrics. 2014;134(5):867-76. doi:10.1542/peds.2014-0309.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43589/psn-pdf
November 17, 2014 - Exploring new avenues to assess the sharp end of patient
safety: an analysis of nationally aggregated peer review
data.
November 17, 2014
Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety:
an analysis of nationally aggregated peer review data. BMJ Qual Saf. 2014;23…
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psnet.ahrq.gov/node/39438/psn-pdf
March 23, 2011 - Time to listen: a review of methods to solicit patient
reports of adverse events.
March 23, 2011
King A, Daniels J, Lim J, et al. Time to listen: a review of methods to solicit patient reports of adverse
events. Qual Saf Health Care. 2010;19(2):148-57. doi:10.1136/qshc.2008.030114.
https://psnet.ahrq.gov/issue/tim…
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psnet.ahrq.gov/node/42946/psn-pdf
January 07, 2015 - Evaluation of medium-term consequences of
implementing commercial computerized physician order
entry and clinical decision support prescribing systems in
two 'early adopter' hospitals.
January 7, 2015
Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences of implementing
commercial compu…
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psnet.ahrq.gov/node/45414/psn-pdf
August 17, 2016 - The next wave of hospital innovation to make patients
safer.
August 17, 2016
Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ.
https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
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psnet.ahrq.gov/node/72512/psn-pdf
November 25, 2020 - The untold story of a cyberattack, a hospital and a dying
woman.
November 25, 2020
Ralston W. Wired Magazine. November 11, 2020.
https://psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman
Health information system downtime can affect patient safety. This story discusses a ransomware incide…
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psnet.ahrq.gov/node/48183/psn-pdf
August 07, 2019 - Get the Medications Right Institute.
August 7, 2019
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
https://psnet.ahrq.gov/issue/get-medications-right-institute
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure
reliable medication use. This institute supports m…
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psnet.ahrq.gov/node/44613/psn-pdf
October 28, 2015 - Getting rid of "never events" in hospitals.
October 28, 2015
Morgenthaler T; Harper CM.
https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals
Never events are devastating and preventable, and health care organizations are under increasing
pressure to eliminate them. This commentary discusses how the Mayo…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
Save
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
March 01, 2015 - PowerPoint Presentation
Spotlight
Two Wrongs Don't Make a Right (Kidney)
This presentation is based on the March 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia
Ed…
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psnet.ahrq.gov/node/33563/psn-pdf
September 16, 2024 - Culture of Safety
September 16, 2024
Culture of Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/culture-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/node/837808/psn-pdf
August 05, 2024 - Recognizing Excellence in Diagnosis: Recommended
Practices for Hospitals.
August 5, 2024
Washington, DC: Leapfrog Group; July 2024.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
Diagnostic safety is beginning to be established as a systemic, rather than solely an ind…
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psnet.ahrq.gov/node/72655/psn-pdf
January 20, 2021 - A night in the hospital, from both ends of the
stethoscope.
January 20, 2021
Ofri D. New York Times. January 5, 2021.
https://psnet.ahrq.gov/issue/night-hospital-both-ends-stethoscope
Physicians have unique perspectives when exposed to health care delivery problems as patients
themselves or as caregivers. T…
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psnet.ahrq.gov/node/851068/psn-pdf
June 28, 2023 - Building a Culture of Safety in Health Care.
June 28, 2023
Chicago, IL: American Hospital Association: May 2023.
https://psnet.ahrq.gov/issue/building-culture-safety-health-care
Healthcare-acquired infections (HAIs) are a common complication of hospital care. This report summarizes
lessons learned at a series of i…
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psnet.ahrq.gov/node/853627/psn-pdf
September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic
Delays.
September 20, 2023
Health Affairs Forefront; May-September 2023.
https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays
Diagnostic delays stem from both human and process failures. This series of articles examines how
s…