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psnet.ahrq.gov/node/39859/psn-pdf
November 21, 2016 - Experience with family activation of rapid response
teams.
November 21, 2016
Bogert S, Ferrell C, Rutledge DN. Experience with family activation of rapid response teams. Medsurg
Nurs. 2010;19(4):215-22; quiz 223.
https://psnet.ahrq.gov/issue/experience-family-activation-rapid-response-teams
The central tenet behi…
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psnet.ahrq.gov/node/850353/psn-pdf
June 14, 2023 - Perioperative handoff enhancement opportunities
through technology and artificial intelligence: a narrative
review.
June 14, 2023
Sparling J, Hong Mershon B, Abraham J. Perioperative handoff enhancement opportunities through
technology and artificial intelligence: a narrative review. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/46749/psn-pdf
April 04, 2018 - Toolkit for Improving Perinatal Safety.
April 4, 2018
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
https://psnet.ahrq.gov/issue/toolkit-improving-perinatal-safety
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from
comprehensive unit-based safe…
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psnet.ahrq.gov/node/74871/psn-pdf
October 01, 2023 - AHRQ Safety Program for MRSA Prevention.
February 14, 2023
Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.
https://psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention
Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. Thi…
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psnet.ahrq.gov/node/40736/psn-pdf
January 04, 2012 - Preventing wrong site, procedure, and patient events
using a common cause analysis.
January 4, 2012
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a
common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/1062860611412066.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/867094/psn-pdf
January 01, 2025 - Maximizing the ability of health IT and AI to improve
patient safety.
November 6, 2024
Singh H, Sittig DF, Classen DC. Maximizing the ability of health IT and AI to improve patient safety. JAMA
Intern Med. 2025;185(1):10-12. doi:10.1001/jamainternmed.2024.4343.
https://psnet.ahrq.gov/issue/maximizing-ability-healt…
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psnet.ahrq.gov/node/867643/psn-pdf
February 26, 2025 - Psychology insights on apologizing to patients.
February 26, 2025
Redelmeier DA, Roach J. Psychology insights on apologizing to patients. J Hosp Med. 2024;Epub Dec 30.
doi:10.1002/jhm.13585.
https://psnet.ahrq.gov/issue/psychology-insights-apologizing-patients
Apologizing to the patient and family after a harmful …
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - To better capture the numbers of cases and deaths, CMS implemented direct mandatory reporting of all
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
Contact
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/node/44067/psn-pdf
June 02, 2015 - Surgical team member assessment of the safety of
surgery practice in 38 South Carolina hospitals.
June 2, 2015
Singer SJ, Jiang W, Huang LC, et al. Surgical team member assessment of the safety of surgery practice
in 38 South Carolina hospitals. Med Care Res Rev. 2015;72(3):298-323. doi:10.1177/1077558715577479.
h…
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psnet.ahrq.gov/node/60960/psn-pdf
September 30, 2020 - COVID-19 pandemic preparation: using simulation for
systems-based learning to prepare the largest healthcare
workforce and system in Canada.
September 30, 2020
Dubé MM, Kaba A, Cronin T, et al. COVID-19 pandemic preparation: using simulation for systems-based
learning to prepare the largest healthcare workforce an…
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psnet.ahrq.gov/node/47638/psn-pdf
February 06, 2019 - Decreasing surgical site infections by developing a high
reliability culture.
February 6, 2019
Pettis AM. Decreasing Surgical Site Infections by Developing a High Reliability Culture. AORN J.
2018;108(6):644-650. doi:10.1002/aorn.12416.
https://psnet.ahrq.gov/issue/decreasing-surgical-site-infections-developing-hi…