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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/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/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/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/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/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/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/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/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/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/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/39920/psn-pdf
October 13, 2010 - Beliefs of ambulatory care physicians about accuracy of
patient medication records and technology-enhanced
solutions to improve accuracy.
October 13, 2010
Weeks DL, Corbett CF, Stream G. Beliefs of ambulatory care physicians about accuracy of patient
medication records and technology-enhanced solutions to improve …
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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/40085/psn-pdf
December 15, 2010 - Medication reconciliation in the emergency department:
opportunities for workflow redesign.
December 15, 2010
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for
workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121.
https://psnet.ah…
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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/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/836790/psn-pdf
March 23, 2022 - Human Factors In Healthcare.
March 23, 2022
Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258.
https://psnet.ahrq.gov/issue/human-factors-healthcare
Human factors concepts are central to improvement in high-risk industries and efforts are emerging to
enfold them into health care organization…
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psnet.ahrq.gov/node/45324/psn-pdf
August 31, 2016 - The problem with medication reconciliation.
August 31, 2016
Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf.
2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734.
https://psnet.ahrq.gov/issue/problem-medication-reconciliation
Medication reconciliation has demonstrated safet…
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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…