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psnet.ahrq.gov/node/37386/psn-pdf
January 06, 2017 - Medication reconciliation in ambulatory oncology.
January 6, 2017
Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual
Patient Saf. 2007;33(12):750-7.
https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology
The Joint Commission mandates systems…
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psnet.ahrq.gov/node/36384/psn-pdf
January 05, 2017 - Forum: The 100,000 Lives Campaign: a scientific and
policy review [with IHI response].
January 5, 2017
Wachter R, Pronovost P. The 100,000 Lives Campaign: A scientific and policy review. Jt Comm J Qual
Patient Saf. 2006;32(11):621-7.
https://psnet.ahrq.gov/issue/forum-100000-lives-campaign-scientific-and-policy-re…
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psnet.ahrq.gov/node/38454/psn-pdf
January 02, 2017 - Comparing process- and outcome-oriented approaches to
voluntary incident reporting in two hospitals.
January 2, 2017
Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to
voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139-45.
https://psn…
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psnet.ahrq.gov/node/38489/psn-pdf
November 25, 2009 - Evaluation of the contributions of an electronic web-
based reporting system: enabling action.
November 25, 2009
Levtzion-Korach O, Alcalai H, Orav EJ, et al. Evaluation of the contributions of an electronic web-based
reporting system: enabling action. J Patient Saf. 2009;52(1):9-15. doi:10.1097/PTS.0b013e318198dc8…
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psnet.ahrq.gov/node/38163/psn-pdf
April 11, 2011 - Retrospective evaluation of a computerized physician
order entry adaptation to prevent prescribing errors in a
pediatric emergency department.
April 11, 2011
Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a computerized physician order entry
adaptation to prevent prescribing errors in a pediatric e…
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psnet.ahrq.gov/node/47247/psn-pdf
December 19, 2018 - Preventing central line–associated bloodstream
infections in the intensive care unit: application of high-
reliability principles.
December 19, 2018
McCraw B, Crutcher T, Polancich S, et al. Preventing Central Line-Associated Bloodstream Infections in
the Intensive Care Unit: Application of High-Reliability Princi…
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psnet.ahrq.gov/node/36044/psn-pdf
April 27, 2010 - Expected and unanticipated consequences of the quality
and information technology revolutions.
April 27, 2010
Wachter R. Expected and unanticipated consequences of the quality and information technology
revolutions. JAMA. 2006;295(23):2780-3.
https://psnet.ahrq.gov/issue/expected-and-unanticipated-consequences-qua…
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psnet.ahrq.gov/node/47550/psn-pdf
November 21, 2018 - Nurses' and patients' appraisals show patient safety in
hospitals remains a concern.
November 21, 2018
Aiken LH, Sloane DM, Barnes H, et al. Nurses' And Patients' Appraisals Show Patient Safety In Hospitals
Remains A Concern. Health Aff (Millwood). 2018;37(11):1744-1751. doi:10.1377/hlthaff.2018.0711.
https://psne…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Culture of Safety
Citation Text:
Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
-
psnet.ahrq.gov/node/33572/psn-pdf
December 15, 2024 - Checklists
December 15, 2024
Checklists. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/checklists
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Background
…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress
Susan Burnett and Charles Vincent, PhD | May 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice
Hardeep Singh, MD, MPH | January 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Singh H. Diagnostic Errors: A New Chapter in Patient Safe…
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024
Also Read the Conversations
In Conversation with Ca…
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psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
June 29, 2023 - Connie's Story: A Nurse's Personal Experience with MRSA
April 1, 2008
View more articles from the same authors.
Citation Text:
Lehfeldt C. Connie's Story: A Nurse's Personal Experience with MRSA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Study
Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.
Citation Text:
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…