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psnet.ahrq.gov/node/61055/psn-pdf
October 21, 2020 - How administrative burdens can harm health.
October 21, 2020
Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.
https://psnet.ahrq.gov/issue/how-administrative-burdens-can-harm-health
The crossover of health equity concepts to patient safety has emerged as a consideration for
improvement. Thi…
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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/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/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/44155/psn-pdf
June 24, 2015 - Patient Safety Tool Kit.
June 24, 2015
WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN:
9789290220596.
https://psnet.ahrq.gov/issue/patient-safety-tool-kit
Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and
s…
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psnet.ahrq.gov/node/45311/psn-pdf
May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd
Edition.
May 20, 2019
Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.
https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition
Checklists are a widely accepted strategy to improve communication and standardize processes to su…
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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/865348/psn-pdf
January 01, 2023 - Learning Health Systems
January 1, 2023
Agency for Health Research and Quality.
https://psnet.ahrq.gov/issue/learning-health-systems
The learning health system model centers on the purposeful, systematic use of internal data and
knowledge with external evidence to improve the safety and quality of care. This websi…
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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/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/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/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/42586/psn-pdf
September 11, 2013 - A hazard of impatient medicine.
September 11, 2013
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
https://psnet.ahrq.gov/issue/hazard-impatient-medicine
This magazine article reports on the unique tension between efficiency mandates and patient-centered
care through the example of a cancer patie…
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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/45540/psn-pdf
November 01, 2016 - Performing the wrong procedure.
November 1, 2016
Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208.
doi:10.1001/jama.2016.9134.
https://psnet.ahrq.gov/issue/performing-wrong-procedure
Describing an incorrect procedure incident which involved placement of a dialysis cath…
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psnet.ahrq.gov/node/837309/psn-pdf
June 01, 2022 - Usability and accessibility of publicly available patient
safety databases.
June 1, 2022
Sheehan JG, Howe JL, Fong A, et al. Usability and accessibility of publicly available patient safety
databases. J Patient Saf. 2022;18(6):565-569. doi:10.1097/pts.0000000000001018.
https://psnet.ahrq.gov/issue/usability-and-ac…
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psnet.ahrq.gov/node/836931/psn-pdf
April 13, 2022 - Quality Special Issue.
April 13, 2022
J Med Imaging Radiat Oncol. 2022;66(2):165-309.
https://psnet.ahrq.gov/issue/quality-special-issue
Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special
issue explores themes related to radiology and radiation oncology, inclu…
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psnet.ahrq.gov/node/60829/psn-pdf
August 19, 2020 - Patient Safety.
August 19, 2020
Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.
https://psnet.ahrq.gov/issue/patient-safety-20
Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair
of special issues highlights the use of simulation in nur…
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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/35349/psn-pdf
November 18, 2011 - Leadership Guide to Patient Safety: Resources and Tools
for Establishing and Maintaining Patient Safety.
November 18, 2011
Botwinick L, Bisognano M, Haraden C. Cambridge, MA: Institute for Healthcare Improvement; 2006.
https://psnet.ahrq.gov/issue/leadership-guide-patient-safety-resources-and-tools-establishin…