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psnet.ahrq.gov/node/35345/psn-pdf
July 20, 2009 - Fixing healthcare from the inside, today.
July 20, 2009
Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78-91, 158.
https://psnet.ahrq.gov/issue/fixing-healthcare-inside-today
This commentary provides a broad overview of the issues facing health care systems in their efforts to
promot…
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psnet.ahrq.gov/node/44387/psn-pdf
August 19, 2015 - Simulation in Surgical Training and Practice.
August 19, 2015
Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
https://psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
Simulation training is being used more broadly as an educational approach in health care. Articles in this
special issue…
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psnet.ahrq.gov/node/60719/psn-pdf
July 22, 2020 - How real-time data can change the patient safety game.
July 22, 2020
Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1.
https://psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
Use of data can improve the response of clinicians to patient concerns and deter…
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psnet.ahrq.gov/node/839328/psn-pdf
November 02, 2022 - Quality and Safety.
November 2, 2022
Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.
https://psnet.ahrq.gov/issue/quality-and-safety-1
Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to
lower-income countries around the world support safe pedia…
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psnet.ahrq.gov/node/38213/psn-pdf
November 12, 2008 - AHRQ announces interest in research on diagnostic
errors in ambulatory care settings.
November 12, 2008
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007.
Publication No. NOT-HS-08-002.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
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psnet.ahrq.gov/node/44468/psn-pdf
September 23, 2015 - LINNEAUS Collaboration on Patient Safety in Primary
Care.
September 23, 2015
Eur J Gen Pract. 2015;(suppl 21):1-77.
https://psnet.ahrq.gov/issue/linneaus-collaboration-patient-safety-primary-care
Collaborative efforts provide learning opportunities for groups that seek to develop widely implementable
improvements…
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psnet.ahrq.gov/node/45508/psn-pdf
September 28, 2016 - Surviving a bad diagnosis.
September 28, 2016
Hobson K. US News News and World Report. September 13, 2016.
https://psnet.ahrq.gov/issue/surviving-bad-diagnosis
Diagnostic error has recently gained recognition as an important patient safety concern. This news article
relates the experiences of patients who were mis…
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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/837076/psn-pdf
May 11, 2022 - AHRQ Challenge on Innovative Solutions To Update or
Re-Create TeamSTEPPS Videos.
May 11, 2022
Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
https://psnet.ahrq.gov/issue/ahrq-challenge-innovative-solutions-update-or-re-create-teamstepps-videos
TeamSTEPPS promotes effective teamwork, collabo…
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psnet.ahrq.gov/node/37793/psn-pdf
February 15, 2011 - Educating seniors to be patient safety self-advocates in
primary care.
February 15, 2011
Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary
Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806.
https://psnet.ahrq.gov/issue/educating-seniors-be-patien…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/node/40152/psn-pdf
January 19, 2011 - Reducing clinical errors in cancer education: interpreter
training.
January 19, 2011
Gany FM, Gonzalez CJ, Basu G, et al. Reducing clinical errors in cancer education: interpreter training. J
Cancer Educ. 2010;25(4):560-4. doi:10.1007/s13187-010-0107-9.
https://psnet.ahrq.gov/issue/reducing-clinical-errors-cancer-…
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psnet.ahrq.gov/node/42442/psn-pdf
July 24, 2013 - Using Plan Do Study Act to transform a simulation center.
July 24, 2013
Murphy JI. Using Plan Do Study Act to Transform a Simulation Center. Clin Simul Nurs. 2012;9(7).
doi:10.1016/j.ecns.2012.03.002.
https://psnet.ahrq.gov/issue/using-plan-do-study-act-transform-simulation-center
This commentary describes the res…
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psnet.ahrq.gov/node/866964/psn-pdf
October 16, 2024 - Pediatric perioperative medication errors.
October 16, 2024
Lu-Boettcher YE, Koka R. Pediatric perioperative medication errors. APSF Newsletter. 39(3):84-86.
https://psnet.ahrq.gov/issue/pediatric-perioperative-medication-errors
Medication safety is a primary concern during surgery, particularly when treating child…
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psnet.ahrq.gov/node/854639/psn-pdf
October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us
to Thrive.
October 18, 2023
Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.
https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
Despite the harm that failure can cause, its value as a learning opportunity, if exam…
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psnet.ahrq.gov/node/60672/psn-pdf
July 08, 2020 - The Care We Need
July 8, 2020
Washington DC: National Quality Forum; 2020.
https://psnet.ahrq.gov/issue/care-we-need
This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach
to improve the US health care system. Five strategic objectives are provided--one of which f…
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psnet.ahrq.gov/node/41401/psn-pdf
January 09, 2018 - Understanding Patient Safety, Third Edition.
January 9, 2018
Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
https://psnet.ahrq.gov/issue/understanding-patient-safety-third-edition
The third edition of this widely read textbook, written by national leaders in patient safety, …
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psnet.ahrq.gov/node/47557/psn-pdf
November 14, 2018 - A Patient-Safe Future.
November 14, 2018
Patient Safety Learning: London, UK; September 2018.
https://psnet.ahrq.gov/issue/patient-safe-future
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report
outlines existing challenges and strategies to drive system improv…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…