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psnet.ahrq.gov/issue/improving-communication-diagnostic-uncertainty-families-hospitalized-children
December 23, 2020 - Challenges to these conversations include lack of time, language discordance, and lack of clarity around
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psnet.ahrq.gov/issue/yours-learning-organization
March 18, 2019 - Key tenets of improving patient safety at the organizational level include taking a systems approach
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psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
August 04, 2021 - These dimensions include safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity
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psnet.ahrq.gov/issue/survey-suggests-disrespectful-behaviors-persist-healthcare-practitioners-speak-yet-again
February 23, 2022 - shares strategies to decrease the presence and impact of disrespectful behaviors in health care which include
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psnet.ahrq.gov/issue/addressing-nursing-shortages-and-patient-safety-using-maslows-hierarchy-needs
April 26, 2023 - Interventions include ensuring staff receive competitive compensation, work to the top of their license
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Steps in responding to patient safety events
include reporting, investigation, communication, remediation … As described in the CANDOR toolkit,
components of an apology should include acknowledging the gaps in … Other improvement efforts include continuing education of health professionals through simulation,
morbidity
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - The indications for tracheostomy include upper airway obstruction (e.g., obstructive sleep apnea; stridor … to head/neck surgery or trauma. 4 The benefits of tracheostomy, compared with endotracheal tubes, include … endotracheal tubes before tracheostomy. 8 Modifiable care-related risk factors for tracheal fistulas include … broader hospital standards. 13,14 Tracheostomy teams can be structured in different ways and often include … Policy and staff education should include airway cuff pressure monitoring technique and protocols.
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psnet.ahrq.gov/issue/methodological-variations-and-their-effects-reported-medication-administration-error-rates
January 15, 2025 - As delayed drug administration is relatively common, studies that did not include such wrong-time errors
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psnet.ahrq.gov/issue/delivering-right-diet-right-patient-every-time
March 27, 2018 - Recommendations to prevent such errors include standardizing practices and using whiteboards as communication
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psnet.ahrq.gov/issue/sops-surveys
December 24, 2008 - Topics covered include organizational characteristics required for successful web-based distribution
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psnet.ahrq.gov/issue/national-patient-safety-foundation
November 23, 2016 - Efforts include the Lucian Leape Institute , an annual conference, awards , a certification program
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psnet.ahrq.gov/issue/safe-intrahospital-transport-non-icu-patient-using-standardized-handoff-communication
March 18, 2010 - These strategies include transport team development, use of standardized communication tools, and educational
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psnet.ahrq.gov/issue/overkill-avalanche-unnecessary-medical-care-harming-patients-physically-and-financially-what
March 29, 2010 - Consequences of unneeded medical care include overtesting, overdiagnosis , and overtreatment.
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psnet.ahrq.gov/issue/antibiotic-stewardship-acute-care-practical-playbook
August 02, 2017 - Core elements include engaging leadership , monitoring effectiveness, and reporting benchmarks.
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psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology
March 19, 2008 - Topics covered include the patient experience , safety culture , disparities , program implementation
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psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
September 13, 2017 - Strategies discussed include reducing variation on measures collected and developing a culture of
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psnet.ahrq.gov/issue/disclosure-medical-errors
September 17, 2018 - Recommendations for improvement include the development of organizational policies that support error
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psnet.ahrq.gov/issue/diagnostic-safety-centers-excellence
December 24, 2008 - Areas of project focus include use of information technology to improve diagnostic accuracy and teamwork
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - This can include a physician updating another at the change of shift, a nurse transitioning a patient … It has also been adapted to include patients and families. … The Joint Commission does not recommend a specific handoff tool, but states the communication should include
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Other well-
documented patient-specific risk factors include limited health literacy and numeracy (the … These include medications
that have dangerous adverse effects, but also include look-alike and sound-alike … These medications include
antidiabetic agents (e.g., insulin), oral anticoagulants (e.g., warfarin)