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psnet.ahrq.gov/node/44720/psn-pdf
December 16, 2015 - The persistent problem of diagnostic error.
December 16, 2015
Lundberg GD. Medscape. December 1, 2015.
https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a
patient safety problem, this commentary out…
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psnet.ahrq.gov/node/50715/psn-pdf
December 04, 2019 - Quality and Safety of Healthcare in Switzerland.
December 4, 2019
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public
Health; 2019.
https://psnet.ahrq.gov/issue/quality-and-safety-healthcare-switzerland
Patient safety is a goal for countries worldwide. This report …
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psnet.ahrq.gov/node/44471/psn-pdf
September 27, 2016 - Two sides of the safety coin?: how patient engagement
and safety climate jointly affect error occurrence in
hospital units.
September 27, 2016
Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety
climate jointly affect error occurrence in hospital units. Health Care …
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psnet.ahrq.gov/node/43400/psn-pdf
August 13, 2014 - Readmission after delayed diagnosis of surgical site
infection: a focus on prevention using the American
College of Surgeons National Surgical Quality
Improvement Program.
August 13, 2014
Gibson A, Tevis S, Kennedy G. Readmission after delayed diagnosis of surgical site infection: a focus on
prevention using the …
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psnet.ahrq.gov/node/43388/psn-pdf
July 30, 2014 - Exploration of an automated approach for receiving
patient feedback after outpatient acute care visits.
July 30, 2014
Berner ES, Ray MN, Panjamapirom A, et al. Exploration of an automated approach for receiving patient
feedback after outpatient acute care visits. J Gen Intern Med. 2014;29(8):1105-12. doi:10.1007/s1…
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psnet.ahrq.gov/node/43049/psn-pdf
October 31, 2014 - Vital signs: improving antibiotic use among hospitalized
patients.
October 31, 2014
Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients.
MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200.
https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospital…
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/47475/psn-pdf
January 23, 2019 - Patient Safety and Quality Improvement.
January 23, 2019
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-0
Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology.
The reviews highlight sy…
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psnet.ahrq.gov/node/61104/psn-pdf
March 03, 2025 - NAM Scholars in Diagnostic Excellence program.
January 10, 2025
National Academy of Medicine and the Council of Medical Specialty Societies.
https://psnet.ahrq.gov/issue/nam-scholars-diagnostic-excellence-program
Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This
…
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psnet.ahrq.gov/node/38701/psn-pdf
June 28, 2011 - Selection of indicators for continuous monitoring of
patient safety: recommendations of the project 'safety
improvement for patients in Europe.'
June 28, 2011
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety:
recommendations of the project 'safety improvement f…
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psnet.ahrq.gov/node/60193/psn-pdf
July 01, 2022 - Improving Diagnosis and Treatment of Maternal Sepsis.
April 1, 2020
Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.
https://psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis
This toolkit focuses on identification of, and rapid response to, sepsis in obstetric p…
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psnet.ahrq.gov/node/847542/psn-pdf
April 12, 2023 - Imagining the future of diagnostic performance feedback.
April 12, 2023
Rosner BI, Zwaan L, Olson APJ. Imagining the future of diagnostic performance feedback. Diagnosis
(Berl). 2023;10(1):31-37. doi:10.1515/dx-2022-0055.
https://psnet.ahrq.gov/issue/imagining-future-diagnostic-performance-feedback
Peer feedback i…
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psnet.ahrq.gov/node/846765/psn-pdf
March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal
Health—Together.
March 29, 2023
Oregon Patient Safety Commission: 2023.
https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together
Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …
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psnet.ahrq.gov/node/36446/psn-pdf
March 28, 2011 - Healthcare provider complaints to the emergency
department: a preliminary report on a new quality
improvement instrument.
March 28, 2011
Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report
on a new quality improvement instrument. Qual Saf Health Care. 2006;15(5):3…
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psnet.ahrq.gov/node/45580/psn-pdf
July 24, 2019 - Overview of Patient Safety Learning Laboratory Projects.
July 24, 2019
Rockville, MD: Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
Collaborative strategies can enable individuals and organizations to learn from each other to support
p…
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psnet.ahrq.gov/issue/reducing-automated-dispensing-cabinet-overrides-peri-anesthesia-care-unit-quality-improvement
June 07, 2023 - Study
Reducing automated dispensing cabinet overrides in the peri-anesthesia care unit: a quality improvement project.
Citation Text:
Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri-anesthesia care unit: a quality improvement projec…
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psnet.ahrq.gov/issue/developing-primary-care-patient-measure-safety-pc-pmos-modified-delphi-process-and-face
August 21, 2015 - Study
Developing a primary care patient measure of safety (PC PMOS): a modified Delphi process and face validity testing.
Citation Text:
Hernan AL, Giles SJ, O'Hara JK, et al. Developing a primary care patient measure of safety (PC PMOS): a modified Delphi process and face validity testi…
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psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
January 17, 2019 - Study
Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy.
Citation Text:
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…
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psnet.ahrq.gov/issue/secondary-analysis-hand-offs-internal-medicine-using-i-pass-mnemonic
April 22, 2013 - Study
Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic.
Citation Text:
Huber A, Moyano B, Blondon K. Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic. BMC Med Educ. 2024;24(1):1046. doi:10.1186/s12909-024-05880-7.
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