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psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
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psnet.ahrq.gov/node/35803/psn-pdf
January 02, 2017 - Operating manual-based usability evaluation of medical
devices: an effective patient safety screening method.
January 2, 2017
Turley JP, Johnson TR, Smith DP, et al. Operating manual-based usability evaluation of medical devices:
an effective patient safety screening method. Jt Comm J Qual Patient Saf. 2006;32(4):2…
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psnet.ahrq.gov/node/38641/psn-pdf
September 02, 2009 - Assessing the value of electronic prescribing in
ambulatory care: A focus group study.
September 2, 2009
Weingart SN, Massagli M, Cyrulik A, et al. Assessing the value of electronic prescribing in ambulatory care:
a focus group study. Int J Med Inform. 2009;78(9):571-8. doi:10.1016/j.ijmedinf.2009.03.007.
https://…
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psnet.ahrq.gov/node/73970/psn-pdf
October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences
with CRPs.
October 13, 2021
Collaborative for Accountability and Improvement. October 21, 2021.
https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…
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psnet.ahrq.gov/node/44636/psn-pdf
November 04, 2015 - The most crucial half-hour at a hospital: the shift change.
November 4, 2015
Landro L.
https://psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change
Information exchange can be challenging when nurses hand off care responsibilities at the end of their
shifts. This news article discusses bedside shift r…
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psnet.ahrq.gov/node/46367/psn-pdf
August 30, 2017 - Why are so many women being misdiagnosed?
August 30, 2017
Mickle K. Glamour. August 11, 2017.
https://psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed
Implicit bias and differences in communication style can affect patient care. This magazine article reports
on factors that contribute to misdiagnosis …
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psnet.ahrq.gov/node/73543/psn-pdf
July 28, 2021 - AMC PSO Resource Center.
July 28, 2021
Academic Medical Center Patient Safety Organization.
https://psnet.ahrq.gov/issue/amc-pso-resource-center
Patient Safety organizations (PSO) are in a unique position to educate their members and the larger
community on patient safety challenges. This PSO resource collection i…
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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/node/846455/psn-pdf
March 22, 2023 - Diagnostic Centers of Excellence (X01 Clinical Trial Not
Allowed).
March 22, 2023
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
Approaching diagnosis as a team activity is seen as a key approach to di…
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psnet.ahrq.gov/node/72515/psn-pdf
January 15, 2025 - AHRQ’s Surveys on Patient Safety Culture® Program: An
Overview for New Users.
December 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025.
https://psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool
An organization’s understanding of its culture is foundational t…
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psnet.ahrq.gov/node/43424/psn-pdf
August 13, 2014 - Office-based anesthesia: safety and outcomes.
August 13, 2014
Shapiro FE, Punwani N, Rosenberg NM, et al. Office-Based Anesthesia. Anesth Analg. 2014;119(2):276-
285. doi:10.1213/ane.0000000000000313.
https://psnet.ahrq.gov/issue/office-based-anesthesia-safety-and-outcomes
Office-based anesthesia has become more w…
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psnet.ahrq.gov/node/40199/psn-pdf
March 03, 2011 - Perspective: malpractice in an academic medical center: a
frequently overlooked aspect of professionalism
education.
March 3, 2011
Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a
frequently overlooked aspect of professionalism education. Acad Med. 2011;86(3):365-8.…
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psnet.ahrq.gov/node/35234/psn-pdf
December 11, 2008 - Using OrgAhead, a computational modeling program, to
improve patient care unit safety and quality outcomes.
December 11, 2008
Effken JA, Brewer BB, Patil A, et al. Using OrgAhead, a computational modeling program, to improve
patient care unit safety and quality outcomes. Int J Med Inform. 2005;74(7-8):605-13.
http…
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psnet.ahrq.gov/node/44718/psn-pdf
November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient
Safety.
November 25, 2015
Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto;
2015.
https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
The 2004 Canadian Adverse Events Study helpe…
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psnet.ahrq.gov/node/46198/psn-pdf
August 16, 2017 - Challenging authority during an emergency—the effect of
a teaching intervention.
August 16, 2017
Friedman Z, Perelman V, McLuckie D, et al. Challenging Authority During an Emergency-the Effect of a
Teaching Intervention. Crit Care Med. 2017;45(8):e814-e820. doi:10.1097/CCM.0000000000002450.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/40749/psn-pdf
September 07, 2011 - Improving the usability of intravenous medication labels
to support safe medication delivery.
September 7, 2011
Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication
delivery. International journal of industrial ergonomics. 2011;41(4):394-399.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/38385/psn-pdf
February 04, 2009 - Impact of a computerized physician order entry system
on nurse-physician collaboration in the medication
process.
February 4, 2009
Pirnejad H, Niazkhani Z, van der Sijs H, et al. Impact of a computerized physician order entry system on
nurse-physician collaboration in the medication process. Int J Med Inform. 2008…
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psnet.ahrq.gov/node/44023/psn-pdf
November 16, 2015 - Impact of organizations on healthcare-associated
infections.
November 16, 2015
Castro-Sánchez E, Holmes AH. Impact of organizations on healthcare-associated infections. J Hosp Infect.
2015;89(4):346-50. doi:10.1016/j.jhin.2015.01.012.
https://psnet.ahrq.gov/issue/impact-organizations-healthcare-associated-infectio…
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psnet.ahrq.gov/node/39900/psn-pdf
October 06, 2010 - Computerized physician order entry of injectable
antineoplastic drugs: an epidemiologic study of
prescribing medication errors.
October 6, 2010
Nerich V, Limat S, Demarchi M, et al. Computerized physician order entry of injectable antineoplastic
drugs: an epidemiologic study of prescribing medication errors. Int J…