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psnet.ahrq.gov/node/42757/psn-pdf
November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector.
November 20, 2013
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
Following the implementation of a large clinical information communicati…
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psnet.ahrq.gov/node/50662/psn-pdf
November 13, 2019 - Deep Dive: Safe Ambulatory Care, Strategies for Patient
Safety & Risk Reduction.
November 13, 2019
Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/deep-dive-safe-ambulatory-care-strategies-patient-safety-risk-reduction
Outpatient safety is gaining traction as a focal point of analysis and …
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psnet.ahrq.gov/node/35701/psn-pdf
July 12, 2010 - Improving the accuracy of patient identification in the
medication-use process.
July 12, 2010
Trapskin PJ, White L, Armitstead JA. Improving the accuracy of patient identification in the medication-use
process. Am J Health Syst Pharm. 2006;63(3):218, 220-2.
https://psnet.ahrq.gov/issue/improving-accuracy-patient-i…
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psnet.ahrq.gov/node/41282/psn-pdf
April 11, 2012 - Analysis of risk factors for adverse drug events in
critically ill patients.
April 11, 2012
Kane-Gill SL, Kirisci L, Verrico MM, et al. Analysis of risk factors for adverse drug events in critically ill
patients*. Crit Care Med. 2012;40(3):823-8. doi:10.1097/CCM.0b013e318236f473.
https://psnet.ahrq.gov/issue/analy…
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psnet.ahrq.gov/node/36993/psn-pdf
September 15, 2011 - A transdisciplinary team acting on evidence through
analyses of moot malpractice cases.
September 15, 2011
Constantino RE. A transdisciplinary team acting on evidence through analyses of moot malpractice cases.
Dimens Crit Care Nurs. 2007;26(4):150-5.
https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evid…
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psnet.ahrq.gov/node/36860/psn-pdf
January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events.
2nd Edition.
January 20, 2016
Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare
Improvement; 2009.
https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition
This white paper describ…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - In Conversation with...David Marx, JD
October 1, 2007
In Conversation with..David Marx, JD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome
Engineering, a risk management firm. …
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm
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January 5, 2021
Innovation
Contact
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Fall prevention is a three-step process: (i) screening for fall risk, (ii) identifying interventions
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - In contrast, Type 2 thinking is more deliberate and requires identifying
features from a diagnostic
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - compartment should prompt investigation
for possible compartment syndrome
29
Compartment Syndrome (7)
• Identifying
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - Developing a more robust
outpatient or home-based palliative team can improve continuity of care by identifying
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Developing a more robust outpatient or home-based palliative team can
improve continuity of care by identifying
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - Reduce Medication Errors
A complete, accurate, and current medication list is a critical tool for identifying
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - Each facility is responsible for identifying the response process.
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psnet.ahrq.gov/node/42869/psn-pdf
January 28, 2017 - Exploring Alternatives To Malpractice Litigation.
January 28, 2017
Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66.
https://psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation
Articles in this special issue cover findings from a federally-funded initiativ…