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psnet.ahrq.gov/node/40058/psn-pdf
January 22, 2017 - Infection preventionist checklist to improve culture and
reduce central line–associated bloodstream infections.
January 22, 2017
Goeschel CA, Holzmueller CG, Cosgrove SE, et al. Infection preventionist checklist to improve culture and
reduce central line-associated bloodstream infections. Jt Comm J Qual Patient Saf…
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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/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/38459/psn-pdf
October 03, 2012 - Identifying opportunities for quality improvement in
surgical site infection prevention.
October 3, 2012
Gagliardi AR, Eskicioglu C, McKenzie M, et al. Identifying opportunities for quality improvement in surgical
site infection prevention. Am J Infect Control. 2009;37(5):398-402. doi:10.1016/j.ajic.2008.10.027.
h…
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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/44359/psn-pdf
January 06, 2016 - What happens when healthcare innovations collide?
January 6, 2016
Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide?
BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441.
https://psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
Innovat…
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psnet.ahrq.gov/node/43316/psn-pdf
July 02, 2014 - Optimizing transitions of care to reduce
rehospitalizations.
July 2, 2014
Li J, Young R, Williams M. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med.
2014;81(5):312-20. doi:10.3949/ccjm.81a.13106.
https://psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations
Care…
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psnet.ahrq.gov/node/73359/psn-pdf
June 02, 2020 - Patient Safety Movement Foundation.
June 2, 2020
15642 Sand Canyon Ave. #51268, Irvine, CA 92619. 877-236-0279, info@psmf.org.
https://psnet.ahrq.gov/issue/patient-safety-movement-foundation
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the
…
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psnet.ahrq.gov/node/43572/psn-pdf
October 08, 2014 - Awareness of patient safety grows with increased
outpatient surgeries.
October 8, 2014
Aston G. Hosp Health Netw. September 9, 2014.
https://psnet.ahrq.gov/issue/awareness-patient-safety-grows-increased-outpatient-surgeries
As outpatient surgery becomes more prevalent, attention around related safety concerns grow…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/46329/psn-pdf
September 06, 2017 - Risk factors of missed colorectal lesions after
colonoscopy.
September 6, 2017
Lee J, Park SW, Kim YS, et al. Risk factors of missed colorectal lesions after colonoscopy. Medicine
(Baltimore). 2017;96(27):e7468. doi:10.1097/MD.0000000000007468.
https://psnet.ahrq.gov/issue/risk-factors-missed-colorectal-lesions-af…
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psnet.ahrq.gov/node/40242/psn-pdf
February 23, 2011 - An anesthesiology department leads culture change at a
hospital system level to improve quality and patient
safety.
February 23, 2011
Fleischut PM, Evans AS, Faggiani SL, et al. An anesthesiology department leads culture change at a
hospital system level to improve quality and patient safety. Anesthesiol Clin. 201…
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psnet.ahrq.gov/node/43234/psn-pdf
June 04, 2014 - Independent double-checks for high-alert medications:
essential practice.
June 4, 2014
Baldwin K, Walsh V. Independent double-checks for high-alert medications: essential practice. Nursing
(Brux). 2014;44(4):65-7. doi:10.1097/01.NURSE.0000444547.64972.dc.
https://psnet.ahrq.gov/issue/independent-double-checks-high…
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psnet.ahrq.gov/node/38600/psn-pdf
October 03, 2017 - Assessment of transparency of cost estimates in
economic evaluations of patient safety programmes.
October 3, 2017
Fukuda H, Imanaka Y. Assessment of transparency of cost estimates in economic evaluations of patient
safety programmes. J Eval Clin Pract. 2009;15(3):451-9. doi:10.1111/j.1365-2753.2008.01033.x.
https…
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psnet.ahrq.gov/node/44475/psn-pdf
October 03, 2017 - Scoring no goal—further adventures in transparency.
October 3, 2017
Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385-
8. doi:10.1056/NEJMp1510094.
https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency
This commentary explores challenges to mon…
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psnet.ahrq.gov/node/44121/psn-pdf
May 13, 2015 - Educating medical trainees on medication reconciliation:
a systematic review.
May 13, 2015
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a
systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
https://psnet.ahrq.gov/issue/educating-medic…
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psnet.ahrq.gov/node/50875/psn-pdf
February 05, 2020 - Implementing Closing the Loop. Safe Practices for
Diagnostic Results
February 5, 2020
Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
Health information technology (HIT) can improve record keepi…
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psnet.ahrq.gov/node/44910/psn-pdf
March 09, 2016 - Systematically Identified Failure Is the Route to a
Successful Health System.
March 9, 2016
Tepper J, Martin D, eds. Healthc Pap. 2015;15(2):4-61.
https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system
Identifying and addressing organizational factors that enable individual m…
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psnet.ahrq.gov/node/36716/psn-pdf
July 26, 2011 - Medication-error reporting and pharmacy resident
experience during implementation of computerized
prescriber order entry.
July 26, 2011
Weant KA, Cook AM, Armitstead JA. Medication-error reporting and pharmacy resident experience during
implementation of computerized prescriber order entry. Am J Health Syst Pharm.…
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psnet.ahrq.gov/node/837336/psn-pdf
June 08, 2022 - Automated identification of diagnostic labelling errors in
medicine.
June 8, 2022
Hautz WE, Kündig MM, Tschanz R, et al. Automated identification of diagnostic labelling errors in medicine.
Diagnosis. 2021;9(2):241-249. doi:10.1515/dx-2021-0039.
https://psnet.ahrq.gov/issue/automated-identification-diagnostic-labe…