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psnet.ahrq.gov/node/45094/psn-pdf
May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care.
May 4, 2016
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-
328.
https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
This analysis found that s…
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psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - Ways to Improve Electronic Health Record Safety.
September 19, 2018
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
Electronic health records both contribute to and detract from safe care. This…
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psnet.ahrq.gov/node/44032/psn-pdf
April 01, 2015 - ACOG Committee Opinion #621: patient safety and health
information technology.
April 1, 2015
Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health
information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/46386/psn-pdf
April 03, 2018 - The impact of electronic health records on diagnosis.
April 3, 2018
Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl).
2017;4(4):211-223. doi:10.1515/dx-2017-0012.
https://psnet.ahrq.gov/issue/impact-electronic-health-records-diagnosis
Health information technol…
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psnet.ahrq.gov/node/44674/psn-pdf
December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care
at Baylor Scott & White Health.
December 18, 2017
Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
Since the publication of the Inst…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - In Conversation With... Remle P. Crowe, PhD
May 16, 2022
In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
Editor’s Note: Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO.
In her professional ro…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - But See the Patient First
Citation Text:
Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE
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April 24, 2024
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Innovation
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January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient as a Team Member in Clinical Care
Curated Library
Foundations
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving
Patient Safety.
Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
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psnet.ahrq.gov/node/47167/psn-pdf
May 30, 2018 - AHRQ Health Information Technology Division's 2017
Annual Report.
May 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-
EF.
https://psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
Health care has worked to enhance use…
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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…
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psnet.ahrq.gov/node/44597/psn-pdf
October 28, 2015 - Smarter clinical checklists: how to minimize checklist
fatigue and maximize clinician performance.
October 28, 2015
Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician
Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47200/psn-pdf
August 20, 2018 - Creating a comprehensive, unit-based approach to
detecting and preventing harm in the neonatal intensive
care unit.
August 20, 2018
Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175.
https://psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-har…
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psnet.ahrq.gov/node/44651/psn-pdf
December 09, 2015 - Measurement of diagnostic errors is a key first step to
their reduction.
December 9, 2015
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
https://psnet.ahrq.gov/issue/measurement-diagnostic-errors-key-first-step-their-reduction
Recently, diagnostic error has garnered much discussion and …
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/45812/psn-pdf
June 22, 2017 - A primer on PDSA: executing plan–do–study–act cycles
in practice, not just in name.
June 22, 2017
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name.
BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
https://psnet.ahrq.gov/issue/primer-pdsa-execu…