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psnet.ahrq.gov/node/73898/psn-pdf
September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.
September 29, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.
https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations
In-depth failure investigations provide improvement insights for individuals and or…
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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/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/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/40274/psn-pdf
December 29, 2014 - Predictors of the perceived impact of a patient safety
collaborative: an exploratory study.
December 29, 2014
Pinto A, Benn J, Burnett S, et al. Predictors of the perceived impact of a patient safety collaborative: an
exploratory study. Int J Qual Health Care. 2011;23(2):173-81. doi:10.1093/intqhc/mzq089.
https://…
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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/854249/psn-pdf
January 01, 2014 - What is safety science?
August 19, 2013
Aven T. What is safety science? Safety Sci. 2014;67:15-20. doi:10.1016/j.ssci.2013.07.026.
https://psnet.ahrq.gov/issue/what-safety-science
Safety is seen as the absence of accidents and safety science research can be used to improve many
industries, including healthcare. Th…
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psnet.ahrq.gov/node/844060/psn-pdf
June 01, 2016 - Developing a measure of value in health care.
June 1, 2016
Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health.
2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009.
https://psnet.ahrq.gov/issue/developing-measure-value-health-care
Value-based healthcare is emerging…
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psnet.ahrq.gov/node/43601/psn-pdf
December 09, 2015 - Special Focus Issue: Patient Safety.
December 9, 2015
Wagner VD, ed. AORN J. 2014;100:351-456.
https://psnet.ahrq.gov/issue/special-focus-issue-patient-safety
Articles in this special issue explore strategies to establish a culture of safety in health care settings,
including coaching to improve team briefing and …
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psnet.ahrq.gov/node/867695/psn-pdf
March 05, 2025 - The Future of Patient and Family Engagement in Quality
and Patient Safety.
March 5, 2025
The Future of Patient and Family Engagement in Quality and Patient Safety. Front Health Serv. 2024.
https://psnet.ahrq.gov/issue/future-patient-and-family-engagement-quality-and-patient-safety
Patient and family engagement in …
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psnet.ahrq.gov/node/39023/psn-pdf
November 19, 2018 - Pediatric Readiness in the Emergency Department.
November 19, 2018
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric Readiness in the Emergency Department.
Pediatrics. 2018;142(5):e20182459. doi:10.1542/peds.2018-2459.
https://psnet.ahrq.gov/issue/pediatric-readiness-emergency-department
This revised set of gu…
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psnet.ahrq.gov/node/862607/psn-pdf
February 14, 2024 - Assessing diagnostic performance.
February 14, 2024
Cosby K, Yang D, Fineberg HV. Assessing diagnostic performance. NEJM Evid.
2024;3(2):EVIDra2300232. doi:10.1056/evidra2300232.
https://psnet.ahrq.gov/issue/assessing-diagnostic-performance
Assessing diagnostic performance to reduce diagnostic errors requires a sh…
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - Back to Basics
March 1, 2007
Hellman R. Back to Basics. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/back-basics
The Case
A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with
right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - Spotlight
Spotlight
Out of Sight, Out of Mind: Out-of-Office Test Result Management
1
Source and Credits
This presentation is based on the May 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Eric Poon, MD, MPH, Duke University School o…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. 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…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - Risk Management and Patient Safety
Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer | December 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Manuel BM, McCarthy JL, Berry WR, et al. Risk Mana…
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - How to Identify and Manage Problem Behaviors
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…