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psnet.ahrq.gov/node/35090/psn-pdf
June 22, 2009 - Improving end of life care: an information systems
approach to reducing medical errors.
June 22, 2009
Tamang S, Kopec D, Shagas G, et al. Improving end of life care: an information systems approach to
reducing medical errors. Stud Health Technol Inform. 2005;114:93-104.
https://psnet.ahrq.gov/issue/improving-end-l…
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psnet.ahrq.gov/node/39500/psn-pdf
January 03, 2017 - Using in situ simulation to improve in-hospital
cardiopulmonary resuscitation.
January 3, 2017
Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary
resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16.
https://psnet.ahrq.gov/issue/using-situ-simulation-improve-h…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics modelling to system safety improvement: present use and future potential.
Citation Text:
The application of system dynamics modelling to system safety improvement: present use and future potential. Ibrah…
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psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcement-examining-impact-artificial
July 22, 2024 - Grant Announcement
Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18).
Citation Text:
Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18). Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261.
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psnet.ahrq.gov/issue/eight-recommendations-policies-communicating-abnormal-test-results
March 10, 2011 - Commentary
Eight recommendations for policies for communicating abnormal test results.
Citation Text:
Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf. 2010;36(5):226-232.
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psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients
October 27, 2021 - Book/Report
What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.
Citation Text:
Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A Diagnostic Process Map To Engage …
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psnet.ahrq.gov/issue/strategies-improving-communication-emergency-department-mediums-and-messages-noisy
November 17, 2010 - Commentary
Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.
Citation Text:
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environ…
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psnet.ahrq.gov/issue/improving-patient-safety-hospitals-contributions-high-reliability-theory-and-normal-accident
October 13, 2010 - Commentary
Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory.
Citation Text:
Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory. Health Serv Res. 2006;…
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psnet.ahrq.gov/issue/patient-safety-part-ii-opportunities-improvement-patient-safety
August 19, 2009 - Review
Patient safety: Part II. Opportunities for improvement in patient safety.
Citation Text:
Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.ja…
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psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician
April 30, 2014 - Study
Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician.
Citation Text:
Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):85…
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psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-reporting-providers-quality-and-safety
November 22, 2017 - Book/Report
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Citation Text:
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/aiming-higher-enhance-professionalism-beyond-accreditation-and-certification
February 03, 2011 - Commentary
Aiming higher to enhance professionalism: beyond accreditation and certification.
Citation Text:
Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-6. doi:10.1001/jama.2015.3818.
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psnet.ahrq.gov/issue/diagnostic-safety-across-transitions-care-throughout-healthcare-system-current-state-and-call
September 13, 2023 - Book/Report
Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.
Citation Text:
Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action. Santhosh L, Cornell E, Rojas JC…
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psnet.ahrq.gov/issue/quality-and-safety-between-ward-and-board-biography-artefacts-study
April 19, 2017 - Government Resource
Quality and Safety Between Ward and Board: a Biography of Artefacts Study.
Citation Text:
Quality and Safety Between Ward and Board: a Biography of Artefacts Study. Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals…
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psnet.ahrq.gov/issue/speaking-and-sharing-information-improves-trainee-neonatal-resuscitations
April 08, 2011 - Study
Speaking up and sharing information improves trainee neonatal resuscitations.
Citation Text:
Katakam LI, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal resuscitations. J Patient Saf. 2012;8(4):202-9. doi:10.1097/PTS.0b013e3182699b4f.
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psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
November 10, 2010 - Commentary
ReCASTing the RCA: an improved model for performing root cause analyses.
Citation Text:
Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…
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psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
February 03, 2021 - Commentary
Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.
Citation Text:
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.000…
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psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles
June 26, 2019 - Commentary
The problem with Plan-Do-Study-Act cycles.
Citation Text:
Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52. doi:10.1136/bmjqs-2015-005076.
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psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children
March 14, 2022 - Commentary
Preventing health care–associated harm in children.
Citation Text:
Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA. 2014;311(17):1731-2. doi:10.1001/jama.2014.2038.
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