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psnet.ahrq.gov/issue/assessing-legislative-potential-institute-error-transparency-state-comparison-malpractice
March 12, 2014 - Study
Assessing legislative potential to institute error transparency: a state comparison of malpractice claims rates.
Citation Text:
Perez B, DiDona T. Assessing Legislative Potential to Institute Error Transparency: A State Comparison of Malpractice Claims Rates. Journal For Healthcare…
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psnet.ahrq.gov/issue/study-deaths-associated-anesthesia-and-surgery-based-study-599-548-anesthesias-ten
August 04, 2021 - Study
Classic
Study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive.
Citation Text:
BEECHER HK, TODD DP. A study of the deaths associated with anesthesia and surgery: based…
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psnet.ahrq.gov/issue/delayed-rapid-response-team-activation-associated-increased-hospital-mortality-morbidity-and
March 16, 2022 - Study
Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution.
Citation Text:
Barwise A, Thongprayoon C, Gajic O, et al. Delayed Rapid Response Team Activation Is Associated With Increased Hospit…
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psnet.ahrq.gov/issue/identification-errors-involving-clinical-laboratories-college-american-pathologists-q-probes
February 15, 2010 - Study
Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.
Citation Text:
Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical …
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psnet.ahrq.gov/issue/specimen-labeling-errors-q-probes-analysis-147-clinical-laboratories
February 15, 2010 - Study
Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.
Citation Text:
Wagar EA, Stankovic AK, Raab SS, et al. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Arch Pathol Lab Med. 2008;132(10):1617-22. doi:10.1043/1543-2165(2008)…
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psnet.ahrq.gov/issue/using-online-quiz-based-reinforcement-system-teach-healthcare-quality-and-patient-safety-and
December 07, 2011 - Study
Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.
Citation Text:
Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach healthcare quality …
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psnet.ahrq.gov/issue/promises-project
January 30, 2019 - Multi-use Website
The PROMISES Project.
Citation Text:
The PROMISES Project. Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School; Health…
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psnet.ahrq.gov/issue/does-lean-management-improve-patient-safety-culture-extensive-evaluation-safety-culture
December 05, 2018 - Study
Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.
Citation Text:
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - If methotrexate is chosen, standard institutional protocols should be in place for assessing whether
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Alarm safety is a National Patient Safety Goal, highlighting the importance of developing institutional
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psnet.ahrq.gov/node/40932/psn-pdf
July 05, 2016 - Health IT and Patient Safety: Building Safer Systems for
Better Care.
July 5, 2016
Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute
of Medicine. Washington, DC: National Academies Press; 2011. ISBN: 9780309221122.
https://psnet.ahrq.gov/issue/health-it-and-pat…
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psnet.ahrq.gov/node/41924/psn-pdf
April 05, 2013 - Disclosure-and-resolution programs that include
generous compensation offers may prompt a complex
patient response.
April 5, 2013
Murtagh L, Gallagher TH, Andrew P, et al. Disclosure-and-resolution programs that include generous
compensation offers may prompt a complex patient response. Health Aff (Millwood). 2012…
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psnet.ahrq.gov/node/41935/psn-pdf
December 19, 2012 - Results of an effort to integrate quality and safety into
medical and nursing school curricula and foster joint
learning.
December 19, 2012
Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and
nursing school curricula and foster joint learning. Health Aff (…
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psnet.ahrq.gov/node/41661/psn-pdf
March 11, 2013 - 'Why is there another person's name on my infusion
bag?' Patient safety in chemotherapy care—a review of
the literature.
March 11, 2013
Kullberg A, Larsen J, Sharp L. 'Why is there another person's name on my infusion bag?' Patient safety in
chemotherapy care - a review of the literature. Eur J Oncol Nurs. 2013;17…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - hospital-based registered nurses spent searching for pillows is one of hundreds of examples of inadequate institutional
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/node/40048/psn-pdf
December 01, 2010 - Temporal trends in rates of patient harm resulting from
medical care.
December 1, 2010
Landrigan CP, Parry G, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical
care. N Engl J Med. 2010;363(22):2124-34. doi:10.1056/NEJMsa1004404.
https://psnet.ahrq.gov/issue/temporal-trends-rates-pati…
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - Transparency when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions.
November 17, 2017
Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248.
doi:10.1097/pts.0000000000000153.
https://psnet.ahrq.gov/issue/transp…