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psnet.ahrq.gov/node/39608/psn-pdf
November 21, 2016 - Institute for Patient- and Family- Centered Care.
November 21, 2016
IPFFC. PO Box 6397, McLean, VA 22106.
https://psnet.ahrq.gov/issue/institute-patient-and-family-centered-care
This organization provides a variety of resources, including webinars and implementation tools, to engage
patients and their family membe…
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psnet.ahrq.gov/node/37152/psn-pdf
September 05, 2007 - Why pay for mistakes?
September 5, 2007
https://psnet.ahrq.gov/issue/why-pay-mistakes
Recently, CMS ruled that Medicare will no longer cover certain preventable errors. In this op-ed piece, the
author discusses why this new rule will drive hospitals to implement safety measures.
https://psnet.ahrq.gov/issue/why-pa…
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Policies and procedures to address discrepancies can be implemented
to ensure discrepancies are resolved
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psnet.ahrq.gov/node/35249/psn-pdf
March 04, 2011 - The patient safety story.
March 4, 2011
Elwyn G, Corrigan JM. The patient safety story. BMJ. 2005;331(7512):302-304.
doi:10.1136/bmj.38562.690104.43.
https://psnet.ahrq.gov/issue/patient-safety-story
The authors provide a brief history of the patient safety movement and insights into why the time is right to
impl…
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psnet.ahrq.gov/node/37073/psn-pdf
August 01, 2007 - An Amendment of the Medical Care Availability and
Reduction of Error (Mcare) Act.
August 1, 2007
Pennsylvania General Assembly.
https://psnet.ahrq.gov/issue/amendment-medical-care-availability-and-reduction-error-mcare-act
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infec…
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psnet.ahrq.gov/node/38858/psn-pdf
August 12, 2009 - Quality and Safety Education.
August 12, 2009
Dolansky MA, Singh MK, eds. Qual Manag Health Care. 2009;18(3):149-227.
https://psnet.ahrq.gov/issue/quality-and-safety-education
This special issue covers topics related to implementing successful patient safety and quality educational
initiatives, such as curriculum …
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - many of these factors are difficult to change, require significant financial investment, and must be implemented
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psnet.ahrq.gov/node/42718/psn-pdf
September 17, 2018 - A Culture of Safety in EMS Systems.
September 17, 2018
Irving, TX: American College of Emergency Physicians; 2014.
https://psnet.ahrq.gov/issue/culture-safety-ems-systems
This guidance recognizes risks associated with emergency medical services and provides
recommendations to support the implementation of a safety…
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psnet.ahrq.gov/node/38916/psn-pdf
July 03, 2013 - Patient Safety Papers 4.
July 3, 2013
Baker GR, ed. Healthc Q. 2009;12(Spec No Patient):1-198.
https://psnet.ahrq.gov/issue/patient-safety-papers-4
This special issue discusses Canadian patient safety efforts in identifying risks, designing safe systems,
implementing solutions, developing learning systems, …
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psnet.ahrq.gov/node/37146/psn-pdf
August 29, 2007 - Medical error reporting system still a year off.
August 29, 2007
Hansen D.
https://psnet.ahrq.gov/issue/medical-error-reporting-system-still-year
This article reports on the progress of implementing a voluntary system for reporting errors, part of the
Patient Safety and Quality Improvement Act.
https://psnet.ahrq…
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psnet.ahrq.gov/node/38230/psn-pdf
August 11, 2010 - The Patient Safety Leadership WalkRounds Guide.
August 11, 2010
Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds-guide
This booklet provides information on the implementation of a WalkRounds program as a cul…
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psnet.ahrq.gov/node/35702/psn-pdf
May 30, 2008 - The Prescription Infrastructre: Are We Ready for
ePrescribing?
May 30, 2008
Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN 1933795026.
https://psnet.ahrq.gov/issue/prescription-infrastructre-are-we-ready-eprescribing
This report outlines the prescription process and the potentia…
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psnet.ahrq.gov/node/40703/psn-pdf
August 17, 2011 - Washington Hospital Center safety program seeks to
catch 'near-misses.'
August 17, 2011
Sun LH.
https://psnet.ahrq.gov/issue/washington-hospital-center-safety-program-seeks-catch-near-misses
This newspaper article reports on one hospital's implementation of an alert system designed to encourage
frontline personne…
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psnet.ahrq.gov/node/37085/psn-pdf
July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and
Technology.
July 15, 2013
Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258.
https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology
This guide provides comprehensive tools for assessment, training, and imple…
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psnet.ahrq.gov/node/39589/psn-pdf
February 13, 2018 - Common cause analysis.
February 13, 2018
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
https://psnet.ahrq.gov/issue/common-cause-analysis
This article describes how one health care system used a multi-event analysis process to identify
medication errors, implement system-level improvements, a…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/node/33997/psn-pdf
March 17, 2011 - Maryland/DC Patient Safety Coalition.
March 17, 2011
https://psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition
The Maryland Patient Safety Center facilitates the study of unsafe practices and the implementation of
practical improvements to prevent errors. The center is a collaboration of two organizations th…
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psnet.ahrq.gov/node/39888/psn-pdf
September 29, 2010 - The electronic medical record in dermatology.
September 29, 2010
Grosshandler JA, Tulbert B, Kaufmann MD, et al. The electronic medical record in dermatology. Arch
Dermatol. 2010;146(9):1031-6. doi:10.1001/archdermatol.2010.229.
https://psnet.ahrq.gov/issue/electronic-medical-record-dermatology
This commentary dis…
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psnet.ahrq.gov/node/37341/psn-pdf
January 20, 2010 - Patient-Centered Care: What Does It Take?
January 20, 2010
Shaller D. The Commonwealth Fund. October 2007.
https://psnet.ahrq.gov/issue/patient-centered-care-what-does-it-take
By sharing the insights of health care leaders, this report identifies important factors for integrating patient-
centered care into organi…
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psnet.ahrq.gov/node/36869/psn-pdf
August 31, 2011 - An extra dose of safety.
August 31, 2011
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-
profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
https://psnet.ahrq.gov/issue/extra-dose-safety
This article describes a healt…