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psnet.ahrq.gov/node/73972/psn-pdf
October 13, 2021 - The less-discussed consequence of healthcare's labor
shortage.
October 13, 2021
Bean M, Masson G. Becker's Hospital Review. October 4, 2021.
https://psnet.ahrq.gov/issue/less-discussed-consequence-healthcares-labor-shortage
Staffing shortages can impact the safety of care by enabling burnout, care omission, a…
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psnet.ahrq.gov/node/73319/psn-pdf
May 26, 2021 - Safety events in children's hospitals during the COVID-19
pandemic.
May 26, 2021
Masonbrink AR, Harris M, Hall M, et al. Hosp Pediatr. 2021;11(6):e95-e100.
https://psnet.ahrq.gov/issue/safety-events-childrens-hospitals-during-covid-19-pandemic
This study analyzed Pediatric Quality Indicators (PDIs) to compare…
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/44636/psn-pdf
November 04, 2015 - The most crucial half-hour at a hospital: the shift change.
November 4, 2015
Landro L.
https://psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change
Information exchange can be challenging when nurses hand off care responsibilities at the end of their
shifts. This news article discusses bedside shift r…
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psnet.ahrq.gov/node/859352/psn-pdf
December 20, 2023 - More hospitals move to confront medical errors head on.
December 20, 2023
Gorenstein D. Tradeoffs. November 16, 2023.
https://psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
Amid governmental guidance to improve safety, front-line perspectives remain an important source for
insight to make im…
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psnet.ahrq.gov/node/849130/psn-pdf
May 17, 2023 - Comparing perspectives on organisational silence: an
analysis of the Gosport inquiry.
May 17, 2023
Powell M. J Health Org Manag. 2023;37(1):67-83.
https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry
Individual, team, and organizational willingness to identify and add…
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psnet.ahrq.gov/node/861295/psn-pdf
January 24, 2024 - Investigators find hospital error caused mother’s death in
Brooklyn.
January 24, 2024
Goldstein J. New York Times. January 14, 2024.
https://psnet.ahrq.gov/issue/investigators-find-hospital-error-caused-mothers-death-brooklyn
Maternal safety is challenged in the Unites States and particularly for minorities. This …
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psnet.ahrq.gov/node/47513/psn-pdf
October 24, 2021 - Measurement and Monitoring of Safety Framework
October 24, 2021
Healthcare Excellence Canada.
https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety-canada-cpsi-safety-improvement-project
Collaboratives are a recognized strategy to support large-scale improvement. This program works to apply
a framework fo…
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psnet.ahrq.gov/node/44816/psn-pdf
June 29, 2016 - Paralyzed by errors, this Xbox designer is taking on
hospital safety.
June 29, 2016
Aleccia J.
https://psnet.ahrq.gov/issue/paralyzed-errors-xbox-designer-taking-hospital-safety
Patients who experience harm while receiving medical care can serve as powerful advocates for patient
safety. This news article reports …
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psnet.ahrq.gov/node/47112/psn-pdf
May 09, 2018 - 34 ways to survive your next trip to the hospital.
May 9, 2018
Crouch M. Reader's Digest. April 2018.
https://psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading
patient safety experts to assist p…
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psnet.ahrq.gov/node/37415/psn-pdf
March 03, 2011 - Six year audit of cardiac arrests and medical emergency
team calls in an Australian outer metropolitan teaching
hospital.
March 3, 2011
Buist M, Harrison J, Abaloz E, et al. Six year audit of cardiac arrests and medical emergency team calls in
an Australian outer metropolitan teaching hospital. BMJ. 2007;335(7631)…
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psnet.ahrq.gov/node/37409/psn-pdf
March 28, 2012 - Extent, nature and consequences of adverse events:
results of a retrospective casenote review in a large NHS
hospital.
March 28, 2012
Sari AB-A, Sheldon T, Cracknell A, et al. Extent, nature and consequences of adverse events: results of a
retrospective casenote review in a large NHS hospital. Qual Saf Health Care…
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psnet.ahrq.gov/node/41320/psn-pdf
May 02, 2012 - Prevalence of error-prone abbreviations used in
medication prescribing for hospitalised patients: multi-
hospital evaluation.
May 2, 2012
Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used in medication prescribing for
hospitalised patients: multi-hospital evaluation. Intern Med J. 2012;42(3)…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
…
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …