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psnet.ahrq.gov/issue/association-simulation-training-rates-medical-malpractice-claims-among-obstetrician
December 02, 2020 - Study
Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.
Citation Text:
Schaffer AC, Babayan A, Einbinder JS, et al. Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists. Ob…
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psnet.ahrq.gov/issue/medical-errors-and-patient-safety-palliative-care-review-current-literature
December 04, 2016 - Review
Medical errors and patient safety in palliative care: a review of current literature.
Citation Text:
Dietz I, Borasio GD, Schneider G, et al. Medical errors and patient safety in palliative care: a review of current literature. J Palliat Med. 2010;13(12):1469-74. doi:10.1089/jpm.2…
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psnet.ahrq.gov/issue/errors-and-nonadherence-pediatric-oral-chemotherapy-use
April 08, 2020 - Study
Errors and nonadherence in pediatric oral chemotherapy use.
Citation Text:
Walsh KE, Ryan J, Daraiseh N, et al. Errors and Nonadherence in Pediatric Oral Chemotherapy Use. Oncology. 2016;91(4):231-236.
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psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis
July 13, 2010 - Study
Liability associated with obstetric anesthesia: a closed claims analysis.
Citation Text:
Davies JM, Posner KL, Lee LA, et al. Liability associated with obstetric anesthesia: a closed claims analysis. Anesthesiology. 2009;110(1):131-139. doi:10.1097/ALN.0b013e318190e16a.
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psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following
October 24, 2018 - Study
Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.
Citation Text:
West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team…
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psnet.ahrq.gov/issue/diagnostic-error-pediatric-hospital-narrative-review
November 16, 2022 - Review
Diagnostic error in the pediatric hospital: a narrative review.
Citation Text:
Sawicki JG, Nystrom DT, Purtell R, et al. Diagnostic error in the pediatric hospital: a narrative review. Hosp Pract (1995). 2021;49((supp1):437-444. doi:10.1080/21548331.2021.2004040.
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psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
December 18, 2014 - Review
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
Citation Text:
Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…
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psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
April 30, 2014 - Study
The Veterans Affairs shift change physician-to-physician handoff project.
Citation Text:
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
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psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
April 24, 2018 - Commentary
Hospice diagnosis: polypharmacy—a teachable moment.
Citation Text:
Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med. 2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253.
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psnet.ahrq.gov/issue/conversations-diagnostic-uncertainty-and-its-management-among-pediatric-acute-care-physicians
March 17, 2021 - Study
Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.
Citation Text:
Patel SJ, Ipsaro A, Brady PW. Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Hosp Pediatr. 2022;12(3):317-324. doi:10.…
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psnet.ahrq.gov/issue/danger-discharge-summaries-abbreviations-create-confusion-both-author-and-recipient
March 15, 2017 - Study
Danger in discharge summaries: abbreviations create confusion for both author and recipient.
Citation Text:
Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: abbreviations create confusion for both author and recipient. Intern Med J. 2023;53(4):550-558. doi:10.1111/i…
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psnet.ahrq.gov/issue/assessing-patient-safety-culture-hospital-settings
August 18, 2021 - Review
Assessing patient safety culture in hospital settings.
Citation Text:
Azyabi A. Assessing patient safety culture in hospital settings. Int J Environ Res Public Health. 2021;18(5):2466. doi:10.3390/ijerph18052466.
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psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-and-strategies
May 01, 2024 - Study
Negative behaviours in health care: prevalence and strategies.
Citation Text:
Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660.
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psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care
November 03, 2021 - Review
A meta-review of methods of measuring and monitoring safety in primary care.
Citation Text:
O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117.
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psnet.ahrq.gov/issue/resilience-and-regulation-odd-couple-consequences-safety-ii-governmental-regulation
October 06, 2021 - Commentary
Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality.
Citation Text:
Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Q…
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psnet.ahrq.gov/issue/are-personal-health-records-phrs-facilitating-patient-safety-scoping-review
February 09, 2022 - Review
Are personal health records (PHRs) facilitating patient safety? A scoping review.
Citation Text:
Joseph AL, Monkman H, Kushniruk AW, et al. Are personal health records (PHRs) facilitating patient safety? A scoping review. Stud Health Technol Inform. 2022;2022:535-539. doi:10.3233/…
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psnet.ahrq.gov/node/33893/psn-pdf
February 19, 2010 - The revolutionary.
February 19, 2010
Swidey N.
https://psnet.ahrq.gov/issue/revolutionary
An introduction to Donald Berwick, CEO of Boston's Institute for Healthcare Improvement, and his vision for
reshaping health care to improve patient safety and quality.
https://psnet.ahrq.gov/issue/revolutionary
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Patient Engagement and Safety
Citation Text:
Patient Engagement and Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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