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psnet.ahrq.gov/node/46727/psn-pdf
August 21, 2021 - Alliance for Innovation on Maternal Health.
August 21, 2021
American College of Obstetricians and Gynecologists.
https://psnet.ahrq.gov/issue/alliance-innovation-maternal-health
This website provides information from a multidisciplinary collaboration whose mission was to support safe
health care for pregnant and p…
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psnet.ahrq.gov/node/60634/psn-pdf
January 01, 2021 - Quality & safety in the time of coronavirus--design better,
learn faster.
July 1, 2020
Fitzsimons J. Quality and safety in the time of Coronavirus: design better, learn faster. Int J Qual Health
Care. 2021;33(1):mzaa051. doi:10.1093/intqhc/mzaa051.
https://psnet.ahrq.gov/issue/quality-safety-time-coronavirus-desig…
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psnet.ahrq.gov/node/73189/psn-pdf
April 28, 2021 - Time out! Rethinking surgical safety: more than just a
checklist.
April 28, 2021
Weinger MB. Time out! Rethinking surgical safety: more than just a checklist. BMJ Qual Saf.
2021;30(8):613-617. doi:10.1136/bmjqs-2020-012600.
https://psnet.ahrq.gov/issue/time-out-rethinking-surgical-safety-more-just-checklist
Check…
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psnet.ahrq.gov/node/36658/psn-pdf
May 27, 2011 - Potassium and phosphorus repletion in hospitalized
patients: implications for clinical practice and the
potential use of healthcare information technology to
improve prescribing and patient safety.
May 27, 2011
Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphorus repletion in hospitalized
patient…
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psnet.ahrq.gov/node/838320/psn-pdf
May 12, 2010 - Regional variations in diagnostic practices.
May 12, 2010
Song Y, Skinner J, Bynum JPW, et al. Regional variations in diagnostic practices. N Engl J Med.
2010;363(1):45-53. doi:10.1056/nejmsa0910881.
https://psnet.ahrq.gov/issue/regional-variations-diagnostic-practices
Improving diagnostic safety is a national pri…
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psnet.ahrq.gov/node/39086/psn-pdf
May 24, 2015 - Psychiatry morbidity and mortality rounds:
implementation and impact.
May 24, 2015
Goldman S, Demaso DR, Kemler B. Psychiatry morbidity and mortality rounds: implementation and impact.
Acad Psychiatry. 2009;33(5):383-8. doi:10.1176/appi.ap.33.5.383.
https://psnet.ahrq.gov/issue/psychiatry-morbidity-and-mortality-r…
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psnet.ahrq.gov/node/839814/psn-pdf
January 01, 2023 - Influencing a culture of quality and safety through
huddles.
November 9, 2022
McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles.
J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642.
https://psnet.ahrq.gov/issue/influencing-culture-quality-a…
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psnet.ahrq.gov/node/838083/psn-pdf
September 14, 2022 - A pause in pediatrics: implementation of a pediatric
diagnostic time-out.
September 14, 2022
Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic
time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010.
https://psnet.ahrq.gov/issue/pause-pediatrics-…
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psnet.ahrq.gov/node/47842/psn-pdf
April 10, 2019 - Learning From Invited Reviews.
April 10, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/learning-invited-reviews
Physical demands and technical complexities can affect surgical safety. This resource is designed to
capture frontline perceptions of surgeons in the United Ki…
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psnet.ahrq.gov/node/838191/psn-pdf
September 28, 2022 - Improved Diagnostic Accuracy Through Probability-
Based Diagnosis.
September 28, 2022
Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-
0026-3-EF.
https://psnet.ahrq.gov/issue/improved-diagnostic-accuracy-through-probability-based-diagnosis
Correct consideration o…
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psnet.ahrq.gov/node/838194/psn-pdf
September 28, 2022 - Measure Dx: implementing pathways to discover and
learn from diagnostic errors.
September 28, 2022
Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic
errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068.
https://psnet.ahrq.gov/issue/meas…
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psnet.ahrq.gov/node/42965/psn-pdf
April 20, 2014 - Development of a Web-based surgical booking and
informed consent system to reduce the potential for error
and improve communication.
April 20, 2014
Siracuse JJ, Benoit E, Burke J, et al. Development of a Web-based surgical booking and informed consent
system to reduce the potential for error and improve communicat…
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psnet.ahrq.gov/node/42456/psn-pdf
September 09, 2013 - A toolkit to disseminate best practices in inpatient
medication reconciliation: Multi-Center Medication
Reconciliation Quality Improvement Study (MARQUIS).
September 9, 2013
Mueller SK, Kripalani S, Stein J, et al. A toolkit to disseminate best practices in inpatient medication
reconciliation: multi-center medicat…
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psnet.ahrq.gov/node/36520/psn-pdf
June 14, 2011 - Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement
programme.
June 14, 2011
Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement programme. Qual Saf Health…
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psnet.ahrq.gov/node/40944/psn-pdf
March 06, 2012 - Using the Agency for Healthcare Research and Quality
Patient Safety Indicators for targeting nursing quality
improvement.
March 6, 2012
Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient
safety indicators for targeting nursing quality improvement. J Nurs Care Qual. …
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psnet.ahrq.gov/node/43974/psn-pdf
April 26, 2015 - 2014 John M. Eisenberg Patient Safety and Quality Award
Recipients Announced.
April 26, 2015
Joint Commission.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
im…
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psnet.ahrq.gov/node/46586/psn-pdf
January 01, 2020 - Adverse event reporting: harnessing residents to improve
patient safety.
November 8, 2017
Tevis SE, Schmocker RK, Wetterneck TB. Adverse Event Reporting. J Patient Saf. 2020;16(4):294-298.
doi:10.1097/pts.0000000000000333.
https://psnet.ahrq.gov/issue/adverse-event-reporting-harnessing-residents-improve-patient-sa…
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psnet.ahrq.gov/node/44660/psn-pdf
December 02, 2015 - The SQUIRE Guidelines: an evaluation from the field, 5
years post release.
December 2, 2015
Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post
release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116.
https://psnet.ahrq.gov/issue/squire-guidel…
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psnet.ahrq.gov/node/74048/psn-pdf
November 10, 2021 - Causes of use errors in ventilation devices--systematic
review.
November 10, 2021
Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl
Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544.
https://psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-s…
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psnet.ahrq.gov/node/42166/psn-pdf
June 10, 2018 - Drawn curtains, muted alarms, and diverted attention lead
to tragedy in the postanesthesia care unit.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
https://psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-
postanesthesia-care-unit
This n…