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psnet.ahrq.gov/node/851660/psn-pdf
July 26, 2023 - From aviation to pediatric surgery.
July 26, 2023
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila).
2024;63(4):557-559. doi:10.1177/00099228231176631.
https://psnet.ahrq.gov/issue/aviation-pediatric-surgery
Human factors strategies are increasingly applied in health …
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psnet.ahrq.gov/node/42370/psn-pdf
June 19, 2013 - Resident Projects for Improvement.
June 19, 2013
Heilman J, ed. UNM CIR Journal of Quality Improvement in Healthcare. Albuquerque, NM: University of
New Mexico; May 2013.
https://psnet.ahrq.gov/issue/journal-quality-improvement-healthcare-second-edition
This publication outlines quality and safety improvement proj…
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psnet.ahrq.gov/node/40677/psn-pdf
August 10, 2011 - Board quality scorecards: measuring improvement.
August 10, 2011
Goeschel CA, Berenholtz SM, Culbertson R, et al. Board quality scorecards: measuring improvement. Am
J Med Qual. 2011;26(4):254-60. doi:10.1177/1062860610389324.
https://psnet.ahrq.gov/issue/board-quality-scorecards-measuring-improvement
Hospital boa…
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psnet.ahrq.gov/node/838184/psn-pdf
September 28, 2022 - The hidden risk of wheelchair use.
September 28, 2022
Quesenberry M. The hidden risk of wheelchair use. Patient Safety. 2022;4(3):6-9.
doi:10.33940/alert/2022.9.1.
https://psnet.ahrq.gov/issue/hidden-risk-wheelchair-use
Medical devices intended to improve patient safety can unintentionally lead to patient harm. Th…
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psnet.ahrq.gov/node/73078/psn-pdf
September 19, 2024 - Risky Business: Creating Connections.
July 17, 2024
Joseph B. Martin Conference Center, Boston, MA; September 19, 2024.
https://psnet.ahrq.gov/issue/risky-business-creating-connections
A core tenant of the patient safety improvement drawing from the experiences of various high-risk
industries to address system saf…
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psnet.ahrq.gov/node/37739/psn-pdf
June 07, 2008 - Health-Care-Associated Infections in Hospitals:
Leadership Needed from HHS to Prioritize Prevention
Practices and Improve Data on these Infections.
June 7, 2008
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-
283.
https://psnet.ahrq.gov/issue/health-care-associa…
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psnet.ahrq.gov/node/44481/psn-pdf
September 09, 2015 - When doctors get it wrong: misdiagnoses are getting a
closer look.
September 9, 2015
Olsen J. Star Tribune. August 30, 2015.
https://psnet.ahrq.gov/issue/when-doctors-get-it-wrong-misdiagnoses-are-getting-closer-look
Diagnostic error is garnering increased attention as a patient safety problem. This news article r…
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psnet.ahrq.gov/node/837679/psn-pdf
July 13, 2022 - Provider implicit bias: bringing awareness to clinical
practice.
July 13, 2022
Moss LD. Clinical Advisor. June 29, 2022.
https://psnet.ahrq.gov/issue/provider-implicit-bias-bringing-awareness-clinical-practice
Health disparities perpetuated by structural racism degrade patient safety. This article discusses the
i…
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psnet.ahrq.gov/node/38582/psn-pdf
May 22, 2023 - Serious Reportable Events in Massachusetts.
May 22, 2023
Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA:
Commonwealth of Massachusetts; 2023.
https://psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
This reoccurring report compiles patient safety…
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psnet.ahrq.gov/node/40439/psn-pdf
July 31, 2012 - Medication error identification rates by pharmacy,
medical, and nursing students.
July 31, 2012
Warholak TL, Queiruga C, Roush R, et al. Medication error identification rates by pharmacy, medical, and
nursing students. Am J Pharm Educ. 2011;75(2):24.
https://psnet.ahrq.gov/issue/medication-error-identification-rat…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…
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psnet.ahrq.gov/node/40580/psn-pdf
July 06, 2011 - Teaching medical error apologies: development of a
multi-component intervention.
July 6, 2011
Gillies RA, Speers SH, Young SE, et al. Teaching medical error apologies: development of a multi-
component intervention. Fam Med. 2011;43(6):400-6.
https://psnet.ahrq.gov/issue/teaching-medical-error-apologies-developmen…
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psnet.ahrq.gov/node/36746/psn-pdf
August 02, 2011 - Patient safety event reporting in critical care: a study of
three intensive care units.
August 2, 2011
Harris CB, Krauss MJ, Coopersmith CM, et al. Patient safety event reporting in critical care: a study of
three intensive care units. Crit Care Med. 2007;35(4):1068-76.
https://psnet.ahrq.gov/issue/patient-safety-…
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psnet.ahrq.gov/node/836788/psn-pdf
March 23, 2022 - A widow’s mission to change NC dental sedation rules.
March 23, 2022
Blythe A. NC Health News. March 10, 2022
https://psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules
Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication
incident and the lack of …
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www.ahrq.gov/evidencenow/heart-health/aspirin/facilitator-checklist.html
August 01, 2018 - Aspirin Use Care: Tasks for the Practice Facilitator
Resource title: Aspirin Use Care: Tasks for the Practice Facilitator
Resource description: This checklist and associated materials are designed to be used with primary care practices to increase aspirin use for secondary prevention of cardiovascular dise…
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www.ahrq.gov/evidencenow/heart-health/smoking/facilitator-checklist.html
August 01, 2018 - Smoking Cessation: Tasks for the Practice Facilitator
Resource title: Smoking Cessation: Tasks for the Practice Facilitator
Resource description: This two-page checklist and associated materials outline working with primary care practices to increase the rate of smoking cessation counseling for patients wh…
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www.ahrq.gov/evidencenow/heart-health/cholesterol/outreach.html
September 01, 2018 - Automated Outreach & Adherence to Cholesterol-Lowering Medication
Resource title: Automated Outreach to Increase Primary Adherence to Cholesterol-Lowering Medications .
Resource description: This journal article summarizes findings from a randomized controlled trial that evaluated an automated system for im…
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psnet.ahrq.gov/node/35858/psn-pdf
July 22, 2010 - How long and how much are nurses now working?
July 22, 2010
Trinkoff AM, Geiger-Brown J, Brady B, et al. How long and how much are nurses now working? Am J Nurs.
2006;106(4):60-72.
https://psnet.ahrq.gov/issue/how-long-and-how-much-are-nurses-now-working
The authors analyzed results from a national survey and foun…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/EzrKKtG83uM-jEB3W3vkvm
Clinical Summary: Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum
Clinical Summary: Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum
Population Newborns
Recommendation
Provide prophylactic ocular topical medication to prevent gonococcal ophthalmia neonatorum.
Grade: A
Preventi…
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digital.ahrq.gov/health-it-tools-and-resources/consumer-engagement-and-human-factors/designing-consumer-health-it-guide-developers-and-systems-designers
January 01, 2023 - Designing Consumer Health IT: A Guide for Developers and Systems Designers
This guide presents suggested recommendations for designers and developers of consumer health IT products.
Download the guide ( PDF , 3 MB)
Recommendations included in the guide are either g…