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psnet.ahrq.gov/node/60162/psn-pdf
March 25, 2020 - Patient Safety Improvement Act of 2020.
March 25, 2020
SB 3380. 116th Congress (2020).
https://psnet.ahrq.gov/issue/patient-safety-improvement-act-2020
This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve
health care-associated infection control efforts, pediatri…
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psnet.ahrq.gov/node/42213/psn-pdf
April 17, 2013 - Quality: performance improvement, teamwork,
information technology and protocols.
April 17, 2013
Coleman NE, Pon S. Quality: performance improvement, teamwork, information technology and protocols.
Crit Care Clin. 2013;29(2):129-51. doi:10.1016/j.ccc.2012.11.002.
https://psnet.ahrq.gov/issue/quality-performance-im…
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psnet.ahrq.gov/node/837708/psn-pdf
July 20, 2022 - Without question.
July 20, 2022
Liebowitz J. Without Question. N Engl J Med. 2022;386(26):2456-2457. doi:10.1056/nejmp2204361.
https://psnet.ahrq.gov/issue/without-question
Diagnostic errors caused by premature closure and anchoring bias occur when clinicians rely on initial
diagnosis despite receiving subsequent …
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psnet.ahrq.gov/node/45064/psn-pdf
April 20, 2016 - Making Care Safer.
April 20, 2016
Agency for Healthcare Research and Quality. Priorities in Focus. March 2016.
https://psnet.ahrq.gov/issue/making-care-safer
The National Quality Strategy is part of AHRQ's ongoing efforts to enhance patient safety. This brief
summarizes the results of the Partnership for Patients …
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psnet.ahrq.gov/node/50668/psn-pdf
November 13, 2019 - Case Study Webinar Series on Clinician Burnout: The
Ohio State University
November 13, 2019
NAM Action Collaborative on Clinician Well-Being and Resilience. Case Study Webinar Series on Clinician
Burnout: The Ohio State University. National Academies of Medicine.
https://psnet.ahrq.gov/issue/case-study-webinar-ser…
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psnet.ahrq.gov/node/44583/psn-pdf
February 17, 2016 - Root Cause Analysis Playbook.
February 17, 2016
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/root-cause-analysis-playbook
Risk management has recently focused on organization-wide improvement in patient safety. This
publication discusses root cause analysis metho…
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psnet.ahrq.gov/node/35034/psn-pdf
November 05, 2015 - Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care. Second edition.
November 5, 2015
Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute for Healthcare Improvement; 2008.
https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-car…
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psnet.ahrq.gov/node/35555/psn-pdf
January 05, 2017 - A comprehensive grassroots model for statewide safety
improvement.
January 5, 2017
Joshi MS, Kazandjian VA, Martin P, et al. A comprehensive grassroots model for statewide safety
improvement. Jt Comm J Qual Patient Saf. 2005;31(12):671-677.
https://psnet.ahrq.gov/issue/comprehensive-grassroots-model-statewide-safe…
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psnet.ahrq.gov/node/38685/psn-pdf
August 18, 2010 - HomeNet: ensuring patient safety with medical device use
in the home.
August 18, 2010
Kaufman D, Weick-Brady M. HomeNet: ensuring patient safety with medical device use in the home. Home
Healthc Nurse. 2009;27(5):300-7.
https://psnet.ahrq.gov/issue/homenet-ensuring-patient-safety-medical-device-use-home
This arti…
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www.ahrq.gov/opioids/about.html
August 01, 2021 - About AHRQ's Work on Opioids and Substance Use Disorders
Deaths from drug overdoses have risen steadily over the past two decades and have become a leading cause of injury death in the United States. The rise in drug overdose deaths was initially driven by misuse of prescription opioids but is now also fueled …
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psnet.ahrq.gov/node/37557/psn-pdf
February 27, 2008 - Learning from patient safety incidents: creating
participative risk regulation in healthcare.
February 27, 2008
Macrae C. Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health
Risk Soc. 2008;10(1). doi:10.1080/13698570701782452.
https://psnet.ahrq.gov/issue/learning-p…
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psnet.ahrq.gov/node/44071/psn-pdf
November 16, 2015 - Quality Improvement in Neurosurgery.
November 16, 2015
Rolston JD, Han SJ, Parsa AT, eds. Neurosurg Clin N Am. 2015;26(2):143-322.
https://psnet.ahrq.gov/issue/quality-improvement-neurosurgery
This special issue covers elements of safe care delivery in neurosurgery and features articles exploring the
use of simula…
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digital.ahrq.gov/funding-mechanism/accelerating-change-and-transformation-organizations-and-networks-action-iv
January 01, 2023 - Accelerating Change and Transformation in Organizations and Networks (ACTION) IV
Clinical Decision Support Innovation Collaborative (CDSiC)
Description
This research continues to build the Clinical Decision Support Innovation Collaborative (CDSiC) to advance the field of pat…
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psnet.ahrq.gov/training-catalog/leading-healthcare-quality-and-safety
August 11, 2025 - Leading Healthcare Quality and Safety
Save
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Organization:
Organization
Coursera
Event Description: Ensuring patient safety and…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-253-maternal-child-outcomes-wic-executive-summary.pdf
April 01, 2022 - Executive Summary_Comparative Effectiveness Review No. 253: Maternal and Child Outcomes Associated With the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC)
Comparative Effectiveness Review
Number 253
Maternal and Child Outcomes Associated With
the Special Supplemental Nutritional P…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-maine-state-snapshot.pdf
January 01, 2018 - Spotlight on Maine -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program
January 2018
This brief highlights the major strategies, lessons learned,
and outcomes from Maine’s experience from February
2010 to February 2016 with the quality demonstration
funded by the Centers for Medicare & Med…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …