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psnet.ahrq.gov/node/45511/psn-pdf
July 21, 2017 - Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient Reporting and
Action for a Safe Environment (PRASE) intervention.
July 21, 2017
Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient R…
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psnet.ahrq.gov/issue/predictors-gaps-patient-safety-and-quality-us-hospitals
December 23, 2020 - Study
Predictors of gaps in patient safety and quality in U.S. hospitals.
Citation Text:
Unruh L, Hofler R. Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals. Health Serv Res. 2016;51(6):2258-2281. doi:10.1111/1475-6773.12468.
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DOI Goog…
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psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
October 14, 2020 - Study
The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.
Citation Text:
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…
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psnet.ahrq.gov/node/73677/psn-pdf
September 08, 2021 - Toolkit for Engaging Patients to Improve Diagnostic
Safety.
September 8, 2021
Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No.
21-0047-2-EF.
https://psnet.ahrq.gov/issue/toolkit-engaging-patients-improve-diagnostic-safety
Patient and family engagement is core to ef…
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psnet.ahrq.gov/node/837593/psn-pdf
June 29, 2022 - Adverse event reporting priorities: an integrative review.
June 29, 2022
Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J
Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945.
https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
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psnet.ahrq.gov/node/46082/psn-pdf
February 25, 2019 - The opioid crisis: can improving diagnosis help solve the
problem?
February 25, 2019
Carr S. ImproveDx. April 2017;4:1-4.
https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem
The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can
contr…
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psnet.ahrq.gov/node/44919/psn-pdf
March 30, 2016 - Rapid response teams improve outcomes—Part 1, Part 2,
and Part 3.
March 30, 2016
Intensive Care Med. 2016;42(4):591-601.
https://psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3
This three-part commentary presents differing views on whether rapid response teams (RRTs) improve
pa…
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psnet.ahrq.gov/node/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…
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psnet.ahrq.gov/node/39042/psn-pdf
July 13, 2010 - Global oximetry: an international anaesthesia quality
improvement project.
July 13, 2010
Walker IA, Merry AF, Wilson IH, et al. Global oximetry: an international anaesthesia quality improvement
project. Anaesthesia. 2009;64(10):1051-60. doi:10.1111/j.1365-2044.2009.06067.x.
https://psnet.ahrq.gov/issue/global-oxim…
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psnet.ahrq.gov/node/43372/psn-pdf
April 13, 2016 - A case for improving measurement of intraoperative
iatrogenic injuries.
April 13, 2016
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries.
JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…
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psnet.ahrq.gov/node/46427/psn-pdf
April 04, 2018 - Improving Diagnosis in Radiology—Progress and
Proposals.
April 4, 2018
Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.
https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals
Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…
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psnet.ahrq.gov/node/865933/psn-pdf
May 22, 2024 - Utilizing pharmacogenomic testing can improve
medication safety and prevent harm.
May 22, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
https://psnet.ahrq.gov/issue/utilizing-pharmacogenomic-testing-can-improve-medication-safety-and-
prevent-harm
Pharmacogenomics (PGx) refers to the impact of gen…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/74114/psn-pdf
November 24, 2021 - Addressing health care disparities by improving quality
and safety.
November 24, 2021
Sentinel Event Alert. Nov 10 2021;(64):1-7.
https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety
Health care disparities are emerging as a core patient safety issue. This alert introduces s…
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psnet.ahrq.gov/node/45642/psn-pdf
November 09, 2016 - Rethinking medical ward quality.
November 9, 2016
Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417.
doi:10.1136/bmj.i5417.
https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality
Patient safety research and commentary often focus on specialized care processes rathe…
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psnet.ahrq.gov/node/42161/psn-pdf
April 03, 2013 - Positioning continuing education: boundaries and
intersections between the domains continuing education,
knowledge translation, patient safety and quality
improvement.
April 3, 2013
Kitto S, Bell M, Peller J, et al. Positioning continuing education: boundaries and intersections between the
domains continuing educ…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/43022/psn-pdf
May 29, 2014 - Using simulation to improve root cause analysis of
adverse surgical outcomes.
May 29, 2014
Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical
outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011.
https://psnet.ahrq.gov/issue/using-sim…
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psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/46243/psn-pdf
June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and
Recovery.
June 5, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery
Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-
based S…