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psnet.ahrq.gov/node/837077/psn-pdf
May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes
away.
May 11, 2022
Kelman B. Kaiser Health News. April 29, 2022.
https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away
Technological solutions harbor unique risks that can result in patient harm. This article shares a response
to report…
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psnet.ahrq.gov/node/39875/psn-pdf
January 22, 2017 - Mobile in situ obstetric emergency simulation and
teamwork training to improve maternal–fetal safety in
hospitals.
January 22, 2017
Guise J-M, Lowe NK, Deering S, et al. Mobile in situ obstetric emergency simulation and teamwork training
to improve maternal-fetal safety in hospitals. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/44863/psn-pdf
July 01, 2016 - Rating the raters: the inconsistent quality of health care
performance measurement.
July 1, 2016
Shahian DM, Normand S-LT, Friedberg MW, et al. Rating the Raters: The Inconsistent Quality of Health
Care Performance Measurement. Ann Surg. 2016;264(1):36-8. doi:10.1097/SLA.0000000000001631.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44564/psn-pdf
October 14, 2015 - Reducing falls with a safety spotter program.
October 14, 2015
Primmer P, Borenstein KK, Downing MT, et al. Reducing falls with a safety spotter program. Nursing
(Brux). 2015;45(8):16-9. doi:10.1097/01.NURSE.0000469244.89222.27.
https://psnet.ahrq.gov/issue/reducing-falls-safety-spotter-program
Patients at high ri…
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psnet.ahrq.gov/node/44190/psn-pdf
June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce
hospital errors.
June 3, 2015
Takahara D. KDVR. May 19, 2015.
https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors
Parents of children who experience harm in the course of medical care serve as advocates to drive saf…
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psnet.ahrq.gov/node/34033/psn-pdf
April 11, 2011 - Adverse events and preventable adverse events in
children.
April 11, 2011
Woods D, Thomas EJ, Holl JL, et al. Adverse events and preventable adverse events in children.
Pediatrics. 2005;115(1):155-60.
https://psnet.ahrq.gov/issue/adverse-events-and-preventable-adverse-events-children
Adverse events in hospitalize…
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psnet.ahrq.gov/node/45326/psn-pdf
January 03, 2017 - Consumer rankings and health care: toward validation
and transparency.
January 3, 2017
Hota B, Webb TA, Stein BD, et al. Consumer Rankings and Health Care: Toward Validation and
Transparency. Jt Comm J Qual Patient Saf. 2016;42(10):439-446.
https://psnet.ahrq.gov/issue/consumer-rankings-and-health-care-toward-vali…
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psnet.ahrq.gov/node/45070/psn-pdf
October 03, 2017 - When There's Harm in the Hospital: Can Transparency
Replace "Deny and Defend"?
October 3, 2017
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend
This report provides the insight…
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psnet.ahrq.gov/issue/advancing-patient-safety-implementation-through-safe-medication-use-research-r18
December 20, 2023 - September 22, 2021
Preventable Hospitalizations: A Window Into Primary and Preventive
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psnet.ahrq.gov/issue/patient-safety-dermatology-review-literature
May 25, 2022 - Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
…
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB,
MA, PhD
April 1, 2019
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Reporting Patient Safety Events
Citation Text:
Reporting Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…