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psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
November 04, 2020 - Study
Performance variability in perioperative sentinel events: report on a nationwide data set.
Citation Text:
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…
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psnet.ahrq.gov/issue/frequency-diagnostic-errors-neonatal-intensive-care-unit-retrospective-cohort-study
April 13, 2022 - Study
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
Citation Text:
Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. J Perinatol. 2022;42(10):1312-131…
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psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters
December 21, 2014 - Study
The effect of facility complexity on perceptions of safety climate in the operating room: size matters.
Citation Text:
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…
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psnet.ahrq.gov/issue/establishing-global-learning-community-incident-reporting-systems
May 24, 2012 - Commentary
Establishing a global learning community for incident-reporting systems.
Citation Text:
Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care. 2010;19(5):446-51. doi:10.1136/qshc.2009.037739.
Copy…
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psnet.ahrq.gov/issue/medication-rounds-tool-promote-medication-safety-children-medical-complexity
February 12, 2020 - Commentary
Medication rounds: a tool to promote medication safety for children with medical complexity.
Citation Text:
Rojas CR, Moore A, Coffin A, et al. Medication rounds: a tool to promote medication safety for children with medical complexity. Jt Comm J Qual Patient Saf. 2023;49(4):2…
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psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate
March 17, 2010 - Study
Organisational culture: variation across hospitals and connection to patient safety climate.
Citation Text:
Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…
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psnet.ahrq.gov/issue/graduate-medical-education-and-patient-safety-busy-and-occasionally-hazardous-intersection
March 02, 2011 - Commentary
Classic
Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.
Citation Text:
Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and occasionally hazardous--intersectio…
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psnet.ahrq.gov/issue/national-healthcare-safety-networks-digital-quality-measures-cdcs-automated-measures
September 23, 2020 - Study
The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety.
Citation Text:
Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality measures: CDC’s automated measures for …
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - Commentary
Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.
Citation Text:
Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097…
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psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature
April 01, 2010 - Review
Safety and risk management interventions in hospitals: a systematic review of the literature.
Citation Text:
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
View more articles from the same authors.
Innovation
Contact
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case April 2008
Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad
Source and Credits
This presentation is based on the April 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sumant Ranji, MD,…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/node/46572/psn-pdf
January 01, 2018 - Effects of efforts to optimise morbidity and mortality
rounds to serve contemporary quality improvement and
educational goals: a systematic review.
December 21, 2017
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to
serve contemporary quality improvement and …
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psnet.ahrq.gov/node/840165/psn-pdf
November 16, 2022 - Evaluation of Quality, Safety and Value in Veterans Health
Administration Facilities, Fiscal 2021.
November 16, 2022
Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-…
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psnet.ahrq.gov/node/74758/psn-pdf
February 09, 2022 - Emotional harm in the radiology department: analysis of
an underrecognized preventable error.
February 9, 2022
Siewert B, Swedeen S, Brook OR, et al. Emotional harm in the radiology department: analysis of an
underrecognized preventable error. Radiology. 2022;302(3):613-619. doi:10.1148/radiol.2021211846.
https://…
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psnet.ahrq.gov/node/47589/psn-pdf
January 09, 2019 - Framework for Effective Board Governance of Health
System Quality.
January 9, 2019
Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare
Improvement; 2018.
https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
The role of hospital boards i…