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psnet.ahrq.gov/node/42147/psn-pdf
March 27, 2013 - The clinical safety of disabled patients: proposal for a
methodology for analysis of health care risks and specific
measures for improvement.
March 27, 2013
Perea-Pérez B, Labajo-González E, Bratos-Murillo M, et al. The clinical safety of disabled patients:
proposal for a methodology for analysis of health care ri…
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psnet.ahrq.gov/node/837001/psn-pdf
April 27, 2022 - Final Report of the Ockenden Review.
April 27, 2022
London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
https://psnet.ahrq.gov/issue/final-report-ockenden-review
Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves
as the final conclusions of an i…
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psnet.ahrq.gov/node/41583/psn-pdf
August 08, 2012 - Achieving the 'perfect handoff' in patient transfers:
building teamwork and trust.
August 8, 2012
Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building
teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-2834.2012.01400.x.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…
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psnet.ahrq.gov/node/37726/psn-pdf
April 30, 2008 - Patient Safety and Quality: An Evidence-Based Handbook
for Nurses.
April 30, 2008
Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No.
08-0043.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-evidence-based-handbook-nurses
This handbook prepared by the Age…
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psnet.ahrq.gov/node/47364/psn-pdf
October 31, 2018 - AI can't replace doctors. But it can make them better.
October 31, 2018
Parikh R. MIT Technol Rev. October 23, 2018.
https://psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making
in health ca…
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psnet.ahrq.gov/node/42327/psn-pdf
June 05, 2013 - Development and testing of tools to detect ambulatory
surgical adverse events.
June 5, 2013
Mull HJ, Borzecki A, Hickson K, et al. Development and testing of tools to detect ambulatory surgical
adverse events. J Patient Saf. 2013;9(2):96-102. doi:10.1097/PTS.0b013e31827d1a88.
https://psnet.ahrq.gov/issue/developme…
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psnet.ahrq.gov/node/854984/psn-pdf
November 01, 2023 - The PRIDx framework to engage payers in reducing
diagnostic errors in healthcare.
November 1, 2023
Ali KJ, Goeschel CA, DeLia DM, et al. The PRIDx framework to engage payers in reducing diagnostic
errors in healthcare. Diagnosis (Berl). 2024;11(1):17-24. doi:10.1515/dx-2023-0042.
https://psnet.ahrq.gov/issue/pridx…
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psnet.ahrq.gov/node/764408/psn-pdf
March 02, 2022 - Ensuring critical instruments and devices are appropriate
for reuse.
March 2, 2022
Quick Safety. February 14, 2022;(64):1-3.
https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …
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psnet.ahrq.gov/node/849338/psn-pdf
May 24, 2023 - The impact of language barriers on patient care: a
pharmacy perspective.
May 24, 2023
Patel J. PM Healthcare Journal. Spring 2023(4):5-18.
https://psnet.ahrq.gov/issue/impact-language-barriers-patient-care-pharmacy-perspective
Language discordance is known to degrade medication safety. The article discusses an exa…
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psnet.ahrq.gov/node/40486/psn-pdf
June 01, 2011 - Process changes to increase compliance with the
Universal Protocol for bedside procedures.
June 1, 2011
Barsuk JH, Brake H, Caprio T, et al. Process changes to increase compliance with the universal protocol
for bedside procedures. Arch Intern Med. 2011;171(10):947-9. doi:10.1001/archinternmed.2011.202.
https://ps…
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psnet.ahrq.gov/node/42139/psn-pdf
March 27, 2013 - Personalised performance feedback reduces narcotic
prescription errors in a NICU.
March 27, 2013
Sullivan KM, Suh S, Monk H, et al. Personalised performance feedback reduces narcotic prescription
errors in a NICU. BMJ Qual Saf. 2013;22(3):256-62. doi:10.1136/bmjqs-2012-001089.
https://psnet.ahrq.gov/issue/personal…
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psnet.ahrq.gov/node/73098/psn-pdf
September 07, 2021 - Achieving Excellence in the Diagnosis of Acute
Cardiovascular Events: Proceedings of a Workshop–in
Brief.
September 7, 2021
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2021.
https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
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psnet.ahrq.gov/node/42500/psn-pdf
August 14, 2013 - When should students learn about ethics,
professionalism and patient safety?
August 14, 2013
Walton M, Jeffery H, Van Staalduinen S, et al. When should students learn about ethics, professionalism
and patient safety? Clin Teach. 2013;10(4):224-9. doi:10.1111/tct.12029.
https://psnet.ahrq.gov/issue/when-should-stud…
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psnet.ahrq.gov/node/38190/psn-pdf
May 14, 2009 - Oncology medication safety: a 3D status report 2008.
May 14, 2009
Johnson PE, Chambers C, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm
Pract. 2008;14(4):169-80. doi:10.1177/1078155208097634.
https://psnet.ahrq.gov/issue/oncology-medication-safety-3d-status-report-2008
This survey di…
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psnet.ahrq.gov/node/44576/psn-pdf
January 23, 2018 - Healthcare Quality and Patient Safety Award.
January 23, 2018
Iowa Healthcare Collaborative.
https://psnet.ahrq.gov/issue/healthcare-quality-and-patient-safety-award
This award seeks to recognize health care organizations and professionals that have exhibited leadership
and innovation in improving patient safety i…
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psnet.ahrq.gov/node/45661/psn-pdf
November 09, 2016 - Center for Diagnostic Excellence.
November 9, 2016
Armstrong Institute for Patient Safety and Quality
https://psnet.ahrq.gov/issue/center-diagnostic-excellence
Diagnostic error has recently been recognized as a serious patient safety concern. Established within the
Armstrong Center for Patient Safety and Quality, …
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psnet.ahrq.gov/node/45229/psn-pdf
July 13, 2016 - The WakeWings journey: creating a patient safety
program.
July 13, 2016
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9.
doi:10.1016/j.aorn.2016.04.004.
https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
Successful and sustainable implementa…
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psnet.ahrq.gov/node/38278/psn-pdf
January 15, 2009 - The impact of introducing medical emergency team
system on the documentations of vital signs.
January 15, 2009
Chen J, Hillman KM, Bellomo R, et al. The impact of introducing medical emergency team system on the
documentations of vital signs. Resuscitation. 2008;80(1). doi:10.1016/j.resuscitation.2008.10.009.
http…
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psnet.ahrq.gov/node/46210/psn-pdf
July 12, 2017 - Could emotional intelligence make patients safer?
July 12, 2017
Codier E, Codier DD. Could Emotional Intelligence Make Patients Safer? Am J Nurs. 2017;117(7):58-62.
doi:10.1097/01.NAJ.0000520946.39224.db.
https://psnet.ahrq.gov/issue/could-emotional-intelligence-make-patients-safer
Nontechnical skill development i…