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psnet.ahrq.gov/node/61067/psn-pdf
January 01, 2021 - A program to provide clinicians with feedback on their
diagnostic performance in a learning health system.
October 28, 2020
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their
diagnostic performance in a learning health system. Jt Comm J Qual Patient Saf. 2021;47(2):120…
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psnet.ahrq.gov/node/72551/psn-pdf
December 09, 2020 - Bundle interventions including nontechnical skills for
surgeons can reduce operative time and improve patient
safety.
December 9, 2020
Koike D, Nomura Y, Nagai M, et al. Bundle interventions including nontechnical skills for surgeons can
reduce operative time and improve patient safety. Int J Qual Health Care. 202…
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psnet.ahrq.gov/node/72856/psn-pdf
March 17, 2021 - The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety
improvements.
March 17, 2021
Paradis KC, Naheedy KW, Matuszak MM, et al. The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety improvements. Pract Radiat Oncol. 2020;1…
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psnet.ahrq.gov/node/73322/psn-pdf
May 26, 2021 - Detecting and assessing suicide ideation during the
COVID-19 pandemic.
May 26, 2021
Simon GE, Stewart CC, Gary MC, et al. Improvement brief: detecting and assessing suicide ideation during
the COVID-19 pandemic. Jt Comm J Qual Patient Saf. 2021;47(7):452-457. doi:10.1016/j.jcjq.2021.04.002.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47980/psn-pdf
May 01, 2019 - Intensive care medicine in 2050: preventing harm.
May 1, 2019
Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med.
2019;45(4):505-507. doi:10.1007/s00134-018-5353-z.
https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
This commentary discusses curren…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/47216/psn-pdf
July 11, 2018 - Progress Made Towards Improving Opioid Safety, But
Further Efforts to Assess Progress and Reduce Risk Are
Needed.
July 11, 2018
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
https://psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-effort…
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psnet.ahrq.gov/node/46257/psn-pdf
October 11, 2017 - Outcomes of concurrent operations: results from the
American College of Surgeons' National Surgical Quality
Improvement Program.
October 11, 2017
Liu JB, Berian JR, Ban KA, et al. Outcomes of Concurrent Operations: Results From the American College
of Surgeons' National Surgical Quality Improvement Program. Ann Su…
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - We have improved communication with the use of SBAR (situation, background, assessment, recommendation
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - of individual carelessness or sloppiness—most are good people trying hard and the systems have to be improved
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psnet.ahrq.gov/node/841467/psn-pdf
December 14, 2022 - patient was initially treated in the intensive care unit with broad-spectrum antibiotics; his
condition improved
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - of individual carelessness or sloppiness—most are good people trying hard and the systems have to be improved
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - recommendations it is expected that patients will achieve more accurate diagnoses, more timely therapies, and improved
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - exclusive use of non-latex products in latex-
allergic patients could be engineered with potential improved
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - September 21, 2022
Increased adherence to perioperative safety guidelines associated with improved
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Paradoxically, late-presenting patients who have sustained this aforementioned process of CS may report improved
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019
Also Read a Conversation
View more articles from the same authors.
Citati…
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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Errors and Near Misses: What Health Care Could Learn
From Aviation
December 1, 2016
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
Perspective
Some of the most urg…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/issue/using-multi-method-user-centred-prospective-hazard-analysis-assess-care-quality-and-patient
May 27, 2011 - Study
Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.
Citation Text:
Dean JE, Hutchinson A, Escoto KH, et al. Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient …