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psnet.ahrq.gov/issue/how-does-routine-disclosure-medical-error-affect-patients-propensity-sue-and-their-assessment
December 04, 2016 - Study
How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality?: Evidence from survey data.
Citation Text:
Helmchen LA, Richards MR, McDonald TB. How does routine disclosure of medical error affect patients' propensity to …
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psnet.ahrq.gov/issue/test-retest-reliability-experienced-global-trigger-tool-review-team
August 03, 2022 - Study
Test-retest reliability of an experienced Global Trigger Tool review team.
Citation Text:
Bjørn B, Anhøj J, Østergaard M, et al. Test-retest reliability of an experienced Global Trigger Tool review team. J Patient Saf. 2021;17(7):e593-e598. doi:10.1097/pts.0000000000000433.
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psnet.ahrq.gov/issue/trigger-tool-detect-harm-pediatric-inpatient-settings
December 07, 2016 - Study
Classic
A trigger tool to detect harm in pediatric inpatient settings.
Citation Text:
Stockwell DC, Bisarya H, Classen D, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-42. doi:10.1542/peds.2014-2152.
C…
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psnet.ahrq.gov/issue/multidisciplinary-approaches-reducing-error-and-risk-patient-care-setting
January 05, 2017 - Study
Classic
Multidisciplinary approaches to reducing error and risk in a patient care setting.
Citation Text:
Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002…
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psnet.ahrq.gov/issue/making-business-case-patient-safety
March 04, 2011 - Commentary
Making the business case for patient safety.
Citation Text:
Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4, 1.
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psnet.ahrq.gov/issue/establishing-global-learning-community-incident-reporting-systems
May 24, 2012 - Commentary
Establishing a global learning community for incident-reporting systems.
Citation Text:
Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care. 2010;19(5):446-51. doi:10.1136/qshc.2009.037739.
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psnet.ahrq.gov/node/38367/psn-pdf
May 24, 2015 - Pathways for Patient Safety.
May 24, 2015
Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group
Management Association; 2009.
https://psnet.ahrq.gov/issue/pathways-patient-safety
This trio of modules provides ambulatory medical practices with tools to develop te…
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psnet.ahrq.gov/node/35155/psn-pdf
April 03, 2008 - Safer Healthcare Now!
April 3, 2008
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/safer-healthcare-now
Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve
patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…
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psnet.ahrq.gov/node/38035/psn-pdf
September 03, 2008 - Incentives for patient safety: holding healthcare
executives accountable.
September 3, 2008
ECRI Institute. Risk Management Reporter. August 2008;27:1-10.
https://psnet.ahrq.gov/issue/incentives-patient-safety-holding-healthcare-executives-accountable
This commentary discusses health care executive responsibility …
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
*
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Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - Can Research Help Us Improve the Medical Liability
System?
March 1, 2012
Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
Perspective
The United States medical malpractice liabili…
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/node/38560/psn-pdf
July 05, 2013 - Safe Surgery Saves Lives.
July 5, 2013
Canadian Patient Safety Institute; CPSI.
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives
This site supports the effort to adopt the World Alliance for Patient Safety surgical checklist program in
Canada.
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives
https://psn…
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psnet.ahrq.gov/node/35589/psn-pdf
June 17, 2010 - Health for life. Keys to safer hospitals.
June 17, 2010
Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8.
https://psnet.ahrq.gov/issue/health-life-keys-safer-hospitals
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of
the 100K L…