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psnet.ahrq.gov/node/47237/psn-pdf
January 01, 2020 - First-year analysis of the Operating Room Black Box
study.
July 25, 2018
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg.
2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
An…
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psnet.ahrq.gov/node/45262/psn-pdf
April 01, 2021 - Each Baby Counts.
April 1, 2021
Royal College of Obstetricians and Gynaecologists.
https://psnet.ahrq.gov/issue/each-baby-counts-key-messages-2015
This organization highlights the importance of in-depth reporting and investigation of adverse events in
labor and delivery, involving parents in the analysis, engaging…
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/issue/contributions-agency-healthcare-research-and-quality-and-grantees
July 29, 2010 - Special or Theme Issue
Contributions by the Agency for Healthcare Research and Quality and Grantees.
Citation Text:
Contributions by the Agency for Healthcare Research and Quality and Grantees. Health Serv Res. 2009 Apr;44(2 Pt 2):623-776.
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S…
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psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative
August 01, 2012 - Government Resource
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative.
Citation Text:
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13…
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psnet.ahrq.gov/issue/economic-analysis-medical-malpractice-liability-and-its-reform
January 31, 2018 - Book/Report
Economic Analysis of Medical Malpractice Liability and Its Reform.
Citation Text:
Economic Analysis of Medical Malpractice Liability and Its Reform. Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No. 13-25.
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psnet.ahrq.gov/node/43660/psn-pdf
November 12, 2014 - Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for Disease
Control and Prevention–convened meeting.
November 12, 2014
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for …
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psnet.ahrq.gov/node/851359/psn-pdf
July 12, 2023 - Evidence for anchoring bias during physician decision-
making.
July 12, 2023
Ly DP, Shekelle PG, Song Z. Evidence for anchoring bias during physician decision-making. JAMA Intern
Med. 2023;183(8):818-823. doi:10.1001/jamainternmed.2023.2366.
https://psnet.ahrq.gov/issue/evidence-anchoring-bias-during-physician-dec…
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psnet.ahrq.gov/node/40427/psn-pdf
May 04, 2011 - Development of a tool within the electronic medical
record to facilitate medication reconciliation after hospital
discharge.
May 4, 2011
Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to
facilitate medication reconciliation after hospital discharge. J Am Med Inf…
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psnet.ahrq.gov/node/46094/psn-pdf
July 11, 2017 - Hiding in plain sight—resurrecting the power of
inspecting the patient.
July 11, 2017
Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA
Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634.
https://psnet.ahrq.gov/issue/hiding-plain-sight-resur…
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - data, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives … considerable resources to improve patient safety.( 2-3 ) Assessing the impact of these patient safety initiatives … specificity, and should probably only be used to help hospitals prioritize chart review and improvement initiatives
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - data, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives … considerable resources to improve patient safety.( 2-3 ) Assessing the impact of these patient safety initiatives … specificity, and should probably only be used to help hospitals prioritize chart review and improvement initiatives
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psnet.ahrq.gov/node/46207/psn-pdf
July 19, 2017 - Burnout Among Health Care Professionals. A Call to
Explore and Address This Underrecognized Threat to
Safe, High-Quality Care.
July 19, 2017
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.
https://psnet.ahrq.gov/issue/burnout-among-health-care-professionals-ca…
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psnet.ahrq.gov/node/47670/psn-pdf
March 20, 2019 - Targeting the fear of safety reporting on a unit level.
March 20, 2019
Copeland D. Targeting the Fear of Safety Reporting on a Unit Level. J Nurs Adm. 2019;49(3):121-124.
doi:10.1097/NNA.0000000000000724.
https://psnet.ahrq.gov/issue/targeting-fear-safety-reporting-unit-level
Blame culture in health care settings …
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psnet.ahrq.gov/node/40263/psn-pdf
March 02, 2011 - Trauma resuscitation errors and computer-assisted
decision support.
March 2, 2011
FitzGerald M, Cameron P, Mackenzie CF, et al. Trauma resuscitation errors and computer-assisted
decision support. Arch Surg. 2011;146(2):218-25. doi:10.1001/archsurg.2010.333.
https://psnet.ahrq.gov/issue/trauma-resuscitation-errors-…
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psnet.ahrq.gov/node/41868/psn-pdf
January 07, 2015 - Changes in end-user satisfaction with computerized
provider order entry over time among nurses and
providers in intensive care units.
January 7, 2015
Hoonakker P, Carayon P, Brown RL, et al. Changes in end-user satisfaction with Computerized Provider
Order Entry over time among nurses and providers in intensive ca…
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psnet.ahrq.gov/node/852283/psn-pdf
January 01, 2024 - Physician engagement in organisational patient safety
through the implementation of a Medical Safety Huddle
initiative: a qualitative study.
August 9, 2023
Rotteau L, Othman D, Dunbar-Yaffe R, et al. Physician engagement in organisational patient safety
through the implementation of a Medical Safety Huddle initiat…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - The federal government and many of its national initiatives, like the Center for
Medicare and Medicaid … I led one of those initiatives, and the Patient-Centered Outcomes
https://psnet.ahrq.gov//#8
https:/
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - In her professional role she serves on committees and initiatives with PQA, NQF, and the National Academy … Authors Anna Legreid Dopp is an employee of ASHP and serves on committees and initiatives with PQA,