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psnet.ahrq.gov/node/41165/psn-pdf
December 08, 2016 - IHI Open School Patient Safety Curriculum
December 8, 2016
Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition
There is a documented interest in postgraduate professional education that enables practicing clinicians to
improve the safety of their actions and beh…
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psnet.ahrq.gov/node/36860/psn-pdf
January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events.
2nd Edition.
January 20, 2016
Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare
Improvement; 2009.
https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition
This white paper describ…
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - May 20, 2019
Engaging residents and fellows to improve institution-wide quality: the
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psnet.ahrq.gov/node/45624/psn-pdf
November 02, 2016 - Addressing the Opioid Crisis in the United States.
November 2, 2016
Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April
2016.
https://psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states
Misuse of opioid medications is currently a serious patient safety conce…
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psnet.ahrq.gov/node/43328/psn-pdf
August 20, 2018 - Safety Quality and Informatics Leadership Program.
August 20, 2018
Harvard Medical School, Boston, MA
https://psnet.ahrq.gov/issue/safety-quality-and-informatics-leadership-program
The Institute of Medicine's learning health system concept serves as the foundation for this year-long
curriculum covering how to appl…
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psnet.ahrq.gov/node/47966/psn-pdf
May 29, 2019 - Patient Safety Essentials Toolkit.
May 29, 2019
Boston, MA: Institute for Healthcare Improvement; 2019.
https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis,
and communication as well as templates to …
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psnet.ahrq.gov/node/41407/psn-pdf
June 19, 2012 - Error disclosure: a new domain for safety culture
assessment.
June 19, 2012
Etchegaray J, Gallagher TH, Bell SK, et al. Error disclosure: a new domain for safety culture assessment.
BMJ Qual Saf. 2012;21(7):594-9. doi:10.1136/bmjqs-2011-000530.
https://psnet.ahrq.gov/issue/error-disclosure-new-domain-safety-cultur…
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psnet.ahrq.gov/node/44917/psn-pdf
November 30, 2016 - Canadian Incident Analysis Framework.
November 30, 2016
Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN:
9781926541440.
https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework
Performing incident analysis can help organizations understand why adverse e…
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psnet.ahrq.gov/node/35283/psn-pdf
July 14, 2010 - Hospitalists as emerging leaders in patient safety:
targeting a few to affect many.
July 14, 2010
Flanders SA, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: targeting a few
to affect many. J Patient Saf. 2005;1(2):78-82. doi:10.1097/pts.0b013e31819751f2.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/60189/psn-pdf
April 01, 2020 - Eliminating Medication Overload: A National Action Plan.
April 1, 2020
Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020.
https://psnet.ahrq.gov/issue/eliminating-medication-overload-national-action-plan
Polypharmacy and medication overuse are known contributors to patient harm. This report …
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psnet.ahrq.gov/node/42812/psn-pdf
August 02, 2016 - Healthcare Practitioner’s Vaccine Error Reporting Form.
August 2, 2016
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/healthcare-practitioners-vaccine-error-reporting-form
This form collects data on errors and concerns associated with vaccines as part of a national reporting
program tracking…
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psnet.ahrq.gov/node/34733/psn-pdf
November 19, 2015 - Out of the Crisis.
November 19, 2015
Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering
Study, 1986. ISBN: 9780911379013.
https://psnet.ahrq.gov/issue/out-crisis
Deming believes that American companies need to transform their method of management to engage and
compete…
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psnet.ahrq.gov/node/863762/psn-pdf
March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week
Webinar.
March 6, 2024
Institute for Healthcare Improvement. March 14, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar
Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
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psnet.ahrq.gov/node/44007/psn-pdf
April 01, 2015 - Time to tackle diagnostic errors. Physicians blame patient
'treadmill' for missed calls.
April 1, 2015
Rice S. Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. Modern
healthcare. 2015;45(3):18-20.
https://psnet.ahrq.gov/issue/time-tackle-diagnostic-errors-physicians-blame-pa…
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psnet.ahrq.gov/node/44115/psn-pdf
June 03, 2015 - An approach to assessing patient safety in hospitals in
low-income countries.
June 3, 2015
Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income
countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628.
https://psnet.ahrq.gov/issue/approach-assessing-…