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psnet.ahrq.gov/node/36510/psn-pdf
June 13, 2011 - Using clinical decision support to improve medication
reconciliation.
June 13, 2011
Moore G. Patient Saf Qual Healthc. November / December 2006.
https://psnet.ahrq.gov/issue/using-clinical-decision-support-improve-medication-reconciliation
The author provides strategies to enhance the value of medication reconcili…
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psnet.ahrq.gov/node/35074/psn-pdf
March 07, 2016 - Library-hospital pairing empowers patients, improves
safety.
March 7, 2016
https://psnet.ahrq.gov/issue/library-hospital-pairing-empowers-patients-improves-safety
This article describes the Partnering for Patient Empowerment Through Community Awareness program,
a model for utilizing libraries to educate consumers …
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psnet.ahrq.gov/node/35123/psn-pdf
July 03, 2015 - Patient Safety Tools: Improving Safety at the Point of
Care.
July 3, 2015
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care
The Agency for Healthcare Research and Quality (AHRQ) awarded more than $8 million to 15 Partnerships
in Implementing …
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psnet.ahrq.gov/node/43441/psn-pdf
July 12, 2018 - Fixing Healthcare Delivery.
July 12, 2018
University of Florida, Institute for Healthcare Improvement, Coursera.
https://psnet.ahrq.gov/issue/fixing-healthcare-delivery
This online course presents teamwork, systems design, leadership, and change management as strategies
to improve health care safety. The course in…
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psnet.ahrq.gov/node/42689/psn-pdf
October 23, 2013 - Solving the puzzle: improving safety outcomes.
October 23, 2013
Whitehouse D. Br J Healthc Manage. 2013;19(9):446-448.
https://psnet.ahrq.gov/issue/solving-puzzle-improving-safety-outcomes
This article illustrates the importance of recognizing complexity when working to create high reliability in
health care.
htt…
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psnet.ahrq.gov/node/33939/psn-pdf
January 17, 2012 - VHA National Patient Safety Improvement Handbook.
January 17, 2012
https://psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
A handbook developed by the VA and the National Center for Patient Safety that provides guidance on how
to limit opportunities that adversely impact patient safety and car…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/38563/psn-pdf
March 23, 2011 - Market-based control mechanisms for patient safety.
March 23, 2011
Coiera E, Braithwaite J. Market-based control mechanisms for patient safety. Qual Saf Health Care.
2009;18(2):99-103. doi:10.1136/qshc.2007.025833.
https://psnet.ahrq.gov/issue/market-based-control-mechanisms-patient-safety
Efforts to improve patie…
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psnet.ahrq.gov/node/44750/psn-pdf
January 06, 2016 - Simulation in the executive suite: lessons learned for
building patient safety leadership.
January 6, 2016
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building
Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
https://psnet.ahrq.gov/issue/simulation-exe…
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psnet.ahrq.gov/node/42917/psn-pdf
February 05, 2014 - The PROMISES Project.
February 5, 2014
Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the
Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School;
Health Care for All; Massachusetts Medical Society; Massachusetts Departme…
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psnet.ahrq.gov/node/36836/psn-pdf
January 29, 2015 - Learning from Bristol: The Report of the Public Inquiry
into Children's Heart Surgery at the Bristol Royal
Infirmary 1984--1995.
January 29, 2015
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-child…
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psnet.ahrq.gov/node/40271/psn-pdf
May 25, 2011 - Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care
unit.
May 25, 2011
Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidem…
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psnet.ahrq.gov/node/844996/psn-pdf
February 22, 2023 - In situ simulation as a tool to longitudinally identify and
track latent safety threats in a structured quality
improvement initiative for SARS-CoV-2 airway
management: a single-center study.
February 22, 2023
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitudinally identify and track late…
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psnet.ahrq.gov/node/60176/psn-pdf
April 01, 2020 - Health and social care-associated harm amongst
vulnerable children in primary care: mixed methods
analysis of national safety reports.
April 1, 2020
Omar A, Rees P, Cooper A, et al. Health and social care-associated harm amongst vulnerable children in
primary care: mixed methods analysis of national safety reports…
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psnet.ahrq.gov/node/40910/psn-pdf
November 09, 2011 - The effect of hospital electronic health record adoption on
nurse-assessed quality of care and patient safety.
November 9, 2011
Kutney-Lee A, Kelly D. The effect of hospital electronic health record adoption on nurse-assessed quality of
care and patient safety. J Nurs Adm. 2011;41(11):466-72. doi:10.1097/NNA.0b013e…
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psnet.ahrq.gov/node/44972/psn-pdf
February 15, 2017 - The effectiveness of electronic differential diagnoses
(DDX) generators: a systematic review and meta-analysis.
February 15, 2017
Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX)
Generators: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(3):e0148991.
doi:…
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psnet.ahrq.gov/node/37707/psn-pdf
March 02, 2011 - Bar-coding surgical sponges to improve safety: a
randomized controlled trial.
March 2, 2011
Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding Surgical Sponges To Improve Safety. Ann
Surg. 2009;247(4). doi:10.1097/sla.0b013e3181656cd5.
https://psnet.ahrq.gov/issue/bar-coding-surgical-sponges-improve-safe…
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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive.
January 3, 2017
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt
Comm J Qual Patient Saf. 2010;36(2):52-61.
https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
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psnet.ahrq.gov/node/37514/psn-pdf
February 04, 2015 - Who pays for medical errors? An analysis of adverse
event costs, the medical liability system, and incentives
for patient safety improvement.
February 4, 2015
Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Adverse Event
Costs, the Medical Liability System, and Incentives for P…
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psnet.ahrq.gov/node/43919/psn-pdf
May 01, 2015 - Association of hospital participation in a quality reporting
program with surgical outcomes and expenditures for
Medicare beneficiaries.
May 1, 2015
Osborne NH, Nicholas LH, Ryan AM, et al. Association of hospital participation in a quality reporting
program with surgical outcomes and expenditures for Medicare ben…