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psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
March 15, 2016 - Study
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
Citation Text:
Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…
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psnet.ahrq.gov/node/43584/psn-pdf
October 22, 2014 - The "Dirty Dozen": 12 persistent safety gaffes that we
need to resolve!
October 22, 2014
ISMP Medication Safety Alert! Acute Care Edition. October 9, 2014;19:1-5.
https://psnet.ahrq.gov/issue/dirty-dozen-12-persistent-safety-gaffes-we-need-resolve
Changes in practice require time and monitoring to achieve lasting …
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psnet.ahrq.gov/node/841790/psn-pdf
September 01, 2021 - Diagnostic errors, health disparities, and artificial
intelligence: a combination for health or harm.
September 1, 2021
Ibrahim SA, Pronovost PJ. Diagnostic errors, health disparities, and artificial intelligence: a combination for
health or harm. JAMA Health Forum. 2021;2(9):e212430. doi:10.1001/jamahealthforum.20…
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psnet.ahrq.gov/node/852460/psn-pdf
August 16, 2023 - Toolkits To Reduce Hypertension in Pregnancy and
Obstetric Hemorrhage.
August 16, 2023
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
https://psnet.ahrq.gov/issue/toolkits-reduce-hypertension-pregnancy-and-obstetric-hemorrhage
Obstetric hemorrhage and severe high blood pressure during pregna…
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psnet.ahrq.gov/node/60064/psn-pdf
March 18, 2020 - Providing Safe, High-Quality Maternity Care in Rural US
Hospitals. IHI Innovation Report.
March 18, 2020
Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
https://psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-
report
Maternal care saf…
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psnet.ahrq.gov/node/33935/psn-pdf
February 05, 2018 - The incidence and severity of adverse events affecting
patients after discharge from the hospital.
February 5, 2018
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients
after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/74755/psn-pdf
February 09, 2022 - Proceed with reasonable care: when legal principles
inform training to prevent harm during the childbirth.
February 9, 2022
Petrovic M, Nicholls J, Siassakos D. Proceed with reasonable care: when legal principles inform training to
prevent harm during childbirth. Best Pract Res Clin Obstet Gynaecol. 2022;80:105-113…
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psnet.ahrq.gov/node/39918/psn-pdf
October 13, 2010 - Reducing catheter-associated bloodstream infections in
the pediatric intensive care unit: business case for quality
improvement.
October 13, 2010
Nowak JE, Brilli RJ, Lake MR, et al. Reducing catheter-associated bloodstream infections in the pediatric
intensive care unit: Business case for quality improvement. Ped…
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psnet.ahrq.gov/node/60880/psn-pdf
September 02, 2020 - Cold debriefings after in-hospital cardiac arrest in an
international pediatric resuscitation quality improvement
collaborative.
September 2, 2020
Wolfe H, Wenger J, Sutton RM, et al. Cold debriefings after in-hospital cardiac arrest in an international
pediatric resuscitation quality improvement collaborative. Pe…
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psnet.ahrq.gov/node/47039/psn-pdf
September 12, 2018 - Overdiagnosis in primary care: framing the problem and
finding solutions.
September 12, 2018
Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ.
2018;362:k2820. doi:10.1136/bmj.k2820.
https://psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-findi…
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psnet.ahrq.gov/node/38443/psn-pdf
February 25, 2009 - High-fidelity, simulation-based, interdisciplinary operating
room team training at the point of care.
February 25, 2009
Paige JT, Kozmenko V, Yang T, et al. High-fidelity, simulation-based, interdisciplinary operating room team
training at the point of care. Surgery. 2009;145(2):138-46. doi:10.1016/j.surg.2008.09.0…
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psnet.ahrq.gov/node/861278/psn-pdf
January 24, 2024 - Interprofessional learning in multidisciplinary healthcare
teams is associated with reduced patient mortality: a
quantitative systematic review and meta-analysis.
January 24, 2024
Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams is
associated with reduced patien…
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psnet.ahrq.gov/node/60664/psn-pdf
July 08, 2020 - Applying the Medications at Transitions and Clinical
Handoffs Toolkit in a rural primary care clinic:
implications for nursing, patients, and caregivers.
July 8, 2020
Jarrett T, Cochran J, Baus A. Applying the Medications at Transitions and Clinical Handoffs Toolkit in a
rural primary care clinic: implications for…
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psnet.ahrq.gov/node/865676/psn-pdf
April 24, 2024 - The National Healthcare Safety Network's digital quality
measures: CDC's automated measures for surveillance of
patient safety.
April 24, 2024
Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality
measures: CDC’s automated measures for surveillance of patient safety. J…
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psnet.ahrq.gov/node/853077/psn-pdf
August 30, 2023 - 2022 John M. Eisenberg Patient Safety and Quality
Awards.
August 30, 2023
Jt Comm J Qual Patient Saf. 2023;49(9):435-450.
https://psnet.ahrq.gov/issue/2022-john-m-eisenberg-patient-safety-and-quality-awards
The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his
pass…
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psnet.ahrq.gov/node/837503/psn-pdf
June 22, 2022 - A clinical reasoning curriculum for medical students: an
interim analysis.
June 22, 2022
Connor DM, Narayana S, Dhaliwal G. A clinical reasoning curriculum for medical students: an interim
analysis. Diagnosis (Berl). 2022;9(2):265-273. doi:10.1515/dx-2021-0112.
https://psnet.ahrq.gov/issue/clinical-reasoning-curri…
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psnet.ahrq.gov/node/839835/psn-pdf
November 09, 2022 - Healthcare Quality and Safety Workforce Report: New
Imperatives for Quality and Safety Mean New Imperatives
for Workforce Development.
November 9, 2022
Chicago, IL: The National Association for Healthcare Quality; 2022.
https://psnet.ahrq.gov/issue/healthcare-quality-and-safety-workforce-report-new-imperatives-qua…
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psnet.ahrq.gov/node/42048/psn-pdf
July 01, 2013 - Striving for a zero-error patient surgical journey through
adoption of aviation-style challenge and response flow
checklists: a quality improvement project.
July 1, 2013
Low DK, Reed MA, Geiduschek JM, et al. Striving for a zero-error patient surgical journey through adoption
of aviation-style challenge and respon…
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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
ht…
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psnet.ahrq.gov/node/41959/psn-pdf
January 16, 2013 - Use of FMEA analysis to reduce risk of errors in
prescribing and administering drugs in paediatric wards:
a quality improvement report.
January 16, 2013
Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and
administering drugs in paediatric wards: a quality improv…