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psnet.ahrq.gov/node/45000/psn-pdf
August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical
Access Hospital (CAH) Changes to Promote Innovation,
Flexibility, and Improvement in Patient Care; Proposed
Rule.
June 29, 2016
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
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psnet.ahrq.gov/node/35588/psn-pdf
February 03, 2011 - Creating a safer health care system: finding the
constraint.
February 3, 2011
Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA.
2005;294(22):2906-8.
https://psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
This editorial builds on the discussi…
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psnet.ahrq.gov/node/47305/psn-pdf
March 19, 2019 - Effect of genetic diagnosis on patients with previously
undiagnosed disease.
March 19, 2019
Splinter K, Adams DR, Bacino CA, et al. Effect of Genetic Diagnosis on Patients with Previously
Undiagnosed Disease. New Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458.
https://psnet.ahrq.gov/issue/effect-gen…
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psnet.ahrq.gov/node/37026/psn-pdf
September 15, 2011 - Residents feel unprepared and unsupervised as leaders
of cardiac arrest teams in teaching hospitals: a survey of
internal medicine residents.
September 15, 2011
Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac
arrest teams in teaching hospitals: a survey of inter…
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psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac…
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psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation.
February 12, 2020
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
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psnet.ahrq.gov/node/844989/psn-pdf
February 22, 2023 - Defining and enhancing collaboration between
community pharmacists and primary care providers to
improve medication safety.
February 22, 2023
White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists
and primary care providers to improve medication safety. Expert Opin D…
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psnet.ahrq.gov/node/73065/psn-pdf
March 24, 2021 - Implementing the clinical occurrence reporting and
learning system: a double-loop learning incident
reporting system in long-term care.
March 24, 2021
Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a
double-loop learning incident reporting system in long-term car…
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psnet.ahrq.gov/node/73107/psn-pdf
April 07, 2021 - Crisis checklists in emergency medicine: another step
forward for cognitive aids.
April 7, 2021
Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids.
BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203.
https://psnet.ahrq.gov/issue/crisis-checklists-em…
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psnet.ahrq.gov/node/45563/psn-pdf
October 19, 2016 - Using a change model to reduce the risk of surgical site
infection.
October 19, 2016
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-
955.
https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
Surgical site infections can resul…
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psnet.ahrq.gov/node/46579/psn-pdf
April 11, 2018 - Electronic medicine can send you test results quickly. But
what if they're scary?
April 11, 2018
Boodman SG. Washington Post. March 26, 2018.
https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary
Although providing patients with access to physician notes and test r…
-
psnet.ahrq.gov/node/45772/psn-pdf
January 11, 2017 - Technical Series on Safer Primary Care.
January 11, 2017
Geneva, Switzerland: World Health Organization; 2016.
https://psnet.ahrq.gov/issue/technical-series-safer-primary-care
Much of patient safety research has focused on the hospital setting, but a majority of health care is
delivered in the ambulatory setting. …
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psnet.ahrq.gov/node/45570/psn-pdf
December 07, 2016 - Getting the Board on Board: What Your Board Needs to
Know About Quality and Safety, Third Edition.
December 7, 2016
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety-
third-edition
Engaging hospital lead…
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psnet.ahrq.gov/node/60235/psn-pdf
April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St
George’s University Hospitals NHS Foundation Trust.
April 15, 2020
NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals
NHS Foundation Trust. NHS England. March 2020.
https://psnet.ahrq.gov/issue/independent-morta…
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/865704/psn-pdf
May 01, 2024 - Supporting error management and safety climate in
ambulatory care practices: the CIRSforte study.
May 1, 2024
Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care
practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-322. doi:10.1097/pts.0000000000001225.
…
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…
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psnet.ahrq.gov/node/44314/psn-pdf
November 06, 2015 - Unintentional discontinuation of chronic medications for
seniors in nursing homes: evaluation of a national
medication reconciliation accreditation requirement using
a population-based cohort study.
November 6, 2015
Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…