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psnet.ahrq.gov/issue/interprofessional-model-speaking-behaviour-healthcare-professionals-qualitative-study
December 21, 2017 - Study
Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study.
Citation Text:
Umoren R, Kim S, Gray MM, et al. Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. BMJ Lead. 2022;6(1):15-19. doi:10.11…
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psnet.ahrq.gov/issue/impact-health-information-technology-detection-potential-adverse-drug-events-ordering-stage
June 25, 2008 - Study
Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Citation Text:
Roberts LL, Ward MM, Brokel JM, et al. Impact of health information technology on detection of potential adverse drug events at the ordering stage. Am J Hea…
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psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care
February 04, 2009 - Study
Shift change handovers and subsequent interruptions: potential impacts on quality of care.
Citation Text:
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.…
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psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous-salvaged-blood
May 11, 2022 - Commentary
Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.
Citation Text:
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in …
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psnet.ahrq.gov/issue/impact-laws-aimed-healthcare-associated-infection-reduction-qualitative-study
December 23, 2020 - Study
Impact of laws aimed at healthcare-associated infection reduction: a qualitative study.
Citation Text:
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/mrsa-infections
September 26, 2018 - Commentary
MRSA Infections.
Citation Text:
Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA. 2007;298(15):1826.
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psnet.ahrq.gov/issue/nurse-vaught-sentenced-deadly-medical-error
January 25, 2023 - Newspaper/Magazine Article
Nurse Vaught sentenced for deadly medical error.
Citation Text:
Nurse Vaught sentenced for deadly medical error. DePeau-Wilson M. MedPage Today. May 13, 2022.
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psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool
December 10, 2024 - Audiovisual Presentation
AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users.
Citation Text:
AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users. Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025.
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psnet.ahrq.gov/issue/patient-safety-spring-2019-final-cdp-report
October 28, 2020 - Book/Report
Patient Safety, Spring 2019 Final CDP Report.
Citation Text:
Patient Safety, Spring 2019 Final CDP Report. Patient Safety Standing Committee. February 6, 2020. Washington DC; National Quality Forum. February 2020.
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psnet.ahrq.gov/issue/veterans-access-care-through-choice-accountability-and-transparency-act-2014
December 21, 2022 - Government Resource
Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014.
Citation Text:
Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014. HR 3230, 113th Congress: 2014.
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psnet.ahrq.gov/issue/jcaho-tightens-leash-medication-reconciliation
April 12, 2006 - Newspaper/Magazine Article
JCAHO tightens leash on medication reconciliation.
Citation Text:
JCAHO tightens leash on medication reconciliation. Perry LE. Drug Topics. March 20, 2006.
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psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias
December 05, 2018 - Newspaper/Magazine Article
‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias.
Citation Text:
‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias. Graham J. Kaiser Health News. October 20, 2021.
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psnet.ahrq.gov/issue/2010-john-m-eisenberg-patient-safety-and-quality-awards
September 03, 2011 - Special or Theme Issue
2010 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2010 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2011;37(5):194-239.
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psnet.ahrq.gov/issue/clinical-reminder-about-safe-use-insulin-vials
June 10, 2018 - Newspaper/Magazine Article
A clinical reminder about the safe use of insulin vials.
Citation Text:
A clinical reminder about the safe use of insulin vials. ISMP Medication Safety Alert! Acute care edition. February 21, 2013;18:1-3.
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psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry
September 29, 2021 - Commentary
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.
Citation Text:
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. Powell M. J Health Org Manag. 2023;37(1):67-83.
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psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases
October 23, 2019 - Newspaper/Magazine Article
How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases.
Citation Text:
How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases. Rein L. Washington Post. August 30, 2019.
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psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
February 11, 2015 - Book/Report
Medicare's Oversight of Ambulatory Surgery Centers Report.
Citation Text:
Medicare's Oversight of Ambulatory Surgery Centers Report. Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
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