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psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed
June 01, 2011 - Commentary
Hospital ratings: a guide for the perplexed.
Citation Text:
Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2. doi:10.1001/jama.2015.5269.
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psnet.ahrq.gov/issue/enhancing-safety-reporting-adult-ambulatory-oncology-clinician-champion-practice-innovation
January 05, 2017 - Study
Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation.
Citation Text:
Weingart SN, Price J, Duncombe D, et al. Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. J Nurs Care …
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psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
August 04, 2021 - Commentary
Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System.
Citation Text:
Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227.
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psnet.ahrq.gov/issue/learning-every-death
June 28, 2011 - Commentary
Learning from every death.
Citation Text:
Huddleston JM, Diedrich DA, Kinsey GC, et al. Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053.
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psnet.ahrq.gov/issue/acgmes-final-duty-hour-standards-special-pgy-1-limits-and-strategic-napping
December 09, 2020 - Commentary
The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.
Citation Text:
Iglehart JK. The ACGME's final duty-hour standards—special PGY-1 limits and strategic napping. N Engl J Med. 2010;363(17):1589-1591.
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psnet.ahrq.gov/issue/building-capacity-and-capability-patient-safety-education-train-trainers-programme-senior
January 15, 2014 - Study
Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors.
Citation Text:
Ahmed M, Arora S, Baker P, et al. Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. BMJ…
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psnet.ahrq.gov/issue/role-south-north-partnerships-promoting-shared-learning-and-knowledge-transfer
July 29, 2020 - Commentary
The role of South--North partnerships in promoting shared learning and knowledge transfer.
Citation Text:
Basu L, Pronovost P, Molello NE, et al. The role of South-North partnerships in promoting shared learning and knowledge transfer. Global Health. 2017;13(1):64. doi:10.1186…
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psnet.ahrq.gov/issue/patient-safety-anatomic-pathology-measuring-discrepancy-frequencies-and-causes
January 08, 2016 - Study
Patient safety in anatomic pathology: measuring discrepancy frequencies and causes.
Citation Text:
Raab SS, Nakhleh RE, Ruby SG. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129(4):459-466.
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psnet.ahrq.gov/issue/nurses-role-medical-error-recovery-integrative-review
September 28, 2005 - Review
Nurses' role in medical error recovery: an integrative review.
Citation Text:
Gaffney TA, Hatcher BJ, Milligan R. Nurses' role in medical error recovery: an integrative review. J Clin Nurs. 2016;25(7-8):906-17. doi:10.1111/jocn.13126.
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psnet.ahrq.gov/issue/functional-health-literacy-and-understanding-medications-discharge
April 24, 2018 - Study
Functional health literacy and understanding of medications at discharge.
Citation Text:
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at discharge. Mayo Clin Proc. 2008;83(5):554-8. doi:10.4065/83.5.554.
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psnet.ahrq.gov/issue/applying-lean-sigma-solutions-mistake-proof-chemotherapy-preparation-process
September 02, 2015 - Commentary
Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.
Citation Text:
Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86.
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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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psnet.ahrq.gov/issue/miles-go-introduction-5-million-lives-campaign
April 04, 2011 - Commentary
Miles to go: an introduction to the 5 Million Lives Campaign.
Citation Text:
McCannon J, Hackbarth AD, Griffin F. Miles to go: an introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf. 2007;33(8):477-84.
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psnet.ahrq.gov/issue/apology-errors-whose-responsibility
September 27, 2016 - Commentary
Apology for errors: whose responsibility?
Citation Text:
Leape L. Apology for errors: whose responsibility? Front Health Serv Manage. 2012;28(3):3-12.
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psnet.ahrq.gov/issue/reducing-disruptive-effects-interruption-cognitive-framework-analysing-costs-and-benefits
September 11, 2013 - Commentary
Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies.
Citation Text:
Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs an…
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psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err-human
November 15, 2016 - Book/Report
Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.
Citation Text:
Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015.
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psnet.ahrq.gov/issue/development-and-implementation-checklists-obstetrics
July 13, 2010 - Commentary
The development and implementation of checklists in obstetrics.
Citation Text:
Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032.
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
August 10, 2025 - Breadcrumb
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - assessment for a palpable lesion is not supported by robust scientific data, although there are two single-institution