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psnet.ahrq.gov/node/40707/psn-pdf
March 11, 2013 - More than words: patients' views on apology and
disclosure when things go wrong in cancer care.
March 11, 2013
Mazor KM, Greene SM, Roblin DW, et al. More than words: patients' views on apology and disclosure
when things go wrong in cancer care. Patient Educ Couns. 2013;90(3):341-346.
doi:10.1016/j.pec.2011.07.010…
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond
the Pandemic: Creating Total Systems Safety
August 30, 2023
McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the
Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/con…
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In most institutions where you are promoting hand hygiene, it is clear that you are also implementing
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
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Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
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Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
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psnet.ahrq.gov/issue/quality-and-patient-safety
December 24, 2008 - Multi-use Website
Quality and Patient Safety.
Citation Text:
Quality and Patient Safety. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/emergency-response-outpatient-oncology-care-improving-patient-safety
March 16, 2023 - Commentary
Emergency response in outpatient oncology care: improving patient safety.
Citation Text:
Schiavone R. Emergency response in outpatient oncology care: improving patient safety. Clin J Oncol Nurs. 2009;13(4):440-2. doi:10.1188/09.CJON.440-442.
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psnet.ahrq.gov/issue/patient-safety-during-perinatal-and-neonatal-care
November 15, 2017 - Special or Theme Issue
Patient Safety During Perinatal and Neonatal Care.
Citation Text:
Patient Safety During Perinatal and Neonatal Care. Am J Perinatol. 2012;29:1-70.
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psnet.ahrq.gov/issue/who-collaborating-centres-patient-safety
April 06, 2016 - Multi-use Website
Global Patient Safety Collaborative.
Citation Text:
Global Patient Safety Collaborative. World Alliance for Patient Safety; World Health Organization
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
Shams B. Syed, MD, MPH | December 1, 2014
Also Read a Conversation
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Citation Text:
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [intern…
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - of 39 delivering hospitals in Arkansas collaborating to reduce maternal mortality and morbidity by implementing
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
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Citation Text:
Van CM, Mossb…
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…