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psnet.ahrq.gov/node/45093/psn-pdf
September 04, 2016 - Radically redesigning patient safety.
September 4, 2016
Radick LE. Radically Redesigning Patient Safety. Healthcare executive. 2016;31(2):32-4, 36-40, 42.
https://psnet.ahrq.gov/issue/radically-redesigning-patient-safety
Leadership and staff commitment are required to achieve improvements in patient safety. Discuss…
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psnet.ahrq.gov/node/45134/psn-pdf
August 10, 2016 - Patient Safety: Exploring Quality of Care in the US.
August 10, 2016
ProPublica, Inc. New York, NY. 2012-2016.
https://psnet.ahrq.gov/issue/patient-safety-exploring-quality-care-us
This website provides resources exploring patient safety challenges from various perspectives, including
feature length articles and m…
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psnet.ahrq.gov/node/44526/psn-pdf
October 07, 2015 - The evolution of a safety culture.
October 7, 2015
Patton BS, Donovan KJ. The Evolution of a Safety Culture. Air Med J. 2015;34(5):264-8.
doi:10.1016/j.amj.2015.05.012.
https://psnet.ahrq.gov/issue/evolution-safety-culture
This commentary describes how an air transport unit at one hospital developed a safety cultu…
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psnet.ahrq.gov/node/38252/psn-pdf
November 26, 2008 - Hospital ethical climate and teamwork in acute care: the
moderating role of leaders.
November 26, 2008
Rathert C, Fleming DA. Hospital ethical climate and teamwork in acute care: the moderating role of
leaders. Health Care Manag Rev. 2008;33(4):323-331. doi:10.1097/01.HCM.0000318769.75018.8d.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45512/psn-pdf
October 05, 2016 - When doctors get the wrong patient.
October 5, 2016
Whitman E. Mod Healthc. September 25, 2016.
https://psnet.ahrq.gov/issue/when-doctors-get-wrong-patient
Misidentification of patients can result in problems such as medication administration delays, blood
transfusion mismatches, and wrong-patient surgery. This ma…
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psnet.ahrq.gov/node/44337/psn-pdf
July 22, 2015 - Patient Safety Supplement.
July 22, 2015
Middleton J, ed. Nursing Times and Health Service Journal. July 2015:s1-s20.
https://psnet.ahrq.gov/issue/patient-safety-supplement
Drawing from presentations at an annual conference in the United Kingdom, articles in this supplement
discuss barcode technologies, the Sign u…
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psnet.ahrq.gov/node/41645/psn-pdf
September 12, 2012 - A safety culture transformation: its effects at a children's
hospital.
September 12, 2012
Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children's hospital. J
Patient Saf. 2012;8(3):125-30. doi:10.1097/PTS.0b013e31824bd744.
https://psnet.ahrq.gov/issue/safety-culture-transfor…
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psnet.ahrq.gov/node/46971/psn-pdf
July 18, 2018 - The Future of NHS Patient Safety Investigation.
July 18, 2018
NHS Improvement. London, UK: National Health Service; 2018.
https://psnet.ahrq.gov/issue/future-nhs-patient-safety-investigation
Organizational processes to investigate adverse care incidents play an important part in generating the
learning needed for …
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psnet.ahrq.gov/node/73078/psn-pdf
September 19, 2024 - Risky Business: Creating Connections.
July 17, 2024
Joseph B. Martin Conference Center, Boston, MA; September 19, 2024.
https://psnet.ahrq.gov/issue/risky-business-creating-connections
A core tenant of the patient safety improvement drawing from the experiences of various high-risk
industries to address system saf…
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psnet.ahrq.gov/node/45027/psn-pdf
April 06, 2016 - Patient Safety 2030.
April 6, 2016
Yu A, Flott K, Chainani N, Fontana G, Darzi A. London, UK: NIHR Imperial Patient Safety Translational
Research Centre; 2016.
https://psnet.ahrq.gov/issue/patient-safety-2030
Examining emerging trends in patient safety improvement work, this report recommends strategies and
tools…
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psnet.ahrq.gov/node/45677/psn-pdf
March 08, 2017 - The War on Error: Common Diagnostic Errors.
March 8, 2017
Medscape. 2016–2017.
https://psnet.ahrq.gov/issue/war-error-common-diagnostic-errors
Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection
highlights particular clinical areas of concern such as neurology an…
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psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
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psnet.ahrq.gov/node/43356/psn-pdf
July 16, 2014 - Introducing the safety score audit for staff member and
patient safety.
July 16, 2014
Sinnott M, Eley R, Winch S. Introducing the safety score audit for staff member and patient safety. AORN
J. 2014;100(1):91-5. doi:10.1016/j.aorn.2014.05.006.
https://psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-membe…
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psnet.ahrq.gov/node/36815/psn-pdf
March 28, 2011 - Implementation of a medication reconciliation process in
an ambulatory internal medicine clinic.
March 28, 2011
Nassaralla CL, Naessens JM, Chaudhry R, et al. Implementation of a medication reconciliation process in
an ambulatory internal medicine clinic. Qual Saf Health Care. 2007;16(2):90-4.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43941/psn-pdf
February 25, 2015 - How to make surgery safer.
February 25, 2015
https://psnet.ahrq.gov/issue/how-make-surgery-safer
This newspaper article reports on various ways hospitals are working to make surgical care safer and
reduce readmissions due to surgical complications, including checklists, teamwork training courses for
surgeons, preo…
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psnet.ahrq.gov/node/42160/psn-pdf
April 03, 2013 - The perianesthesia nurse's role in the prevention of
opioid-related sentinel events.
April 3, 2013
Pasero C. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. J Perianesth
Nurs. 2013;28(1):31-7. doi:10.1016/j.jopan.2012.11.001.
https://psnet.ahrq.gov/issue/perianesthesia-nurses-r…
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psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
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psnet.ahrq.gov/node/73123/psn-pdf
April 01, 2020 - Digital Healthcare Research.
April 1, 2020
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/digital-healthcare-research
An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and
health system improvement is still emerging. This website hi…
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psnet.ahrq.gov/node/850935/psn-pdf
June 21, 2023 - Non–operating room anesthesia challenges.
June 21, 2023
Smith MJ. Anesthesiology News. June 6, 2023.
https://psnet.ahrq.gov/issue/non-operating-room-anesthesia-challenges
The use of office-based anesthesia presents both care improvements and risks for patients and clinical
teams. This article summarizes frontline …
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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