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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - The most successful learning health systems have had some institutional investment behind them and alignment
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - The most successful learning health systems have had some institutional investment behind them and alignment
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psnet.ahrq.gov/node/41494/psn-pdf
June 27, 2012 - National Voluntary Consensus Standards for Patient
Safety Measures: A Consensus Report.
June 27, 2012
Washington, DC: National Quality Forum; June 2012.
https://psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-
report
Progress in improving patient safety has been hampe…
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psnet.ahrq.gov/node/37562/psn-pdf
June 14, 2011 - Effectiveness and efficiency of root cause analysis in
medicine.
June 14, 2011
Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687.
doi:10.1001/jama.299.6.685.
https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine
Application of root c…
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psnet.ahrq.gov/node/40020/psn-pdf
September 20, 2011 - Case 34-2010: a 65-year-old woman with an incorrect
operation on the left hand.
September 20, 2011
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a
65-year-old woman with an incorrect operation on the left hand. N Engl J Med. 2010;363(20):1950-7.
doi:10.1056/NEJMcp…
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psnet.ahrq.gov/node/39173/psn-pdf
November 02, 2014 - Transforming healthcare: a safety imperative.
November 2, 2014
Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care.
2009;18(6):424-8. doi:10.1136/qshc.2009.036954.
https://psnet.ahrq.gov/issue/transforming-healthcare-safety-imperative
Although significant progres…
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psnet.ahrq.gov/node/47856/psn-pdf
June 02, 2019 - The impact of patient–physician alliance on trust
following an adverse event.
June 2, 2019
Shoemaker K, Smith CP. The impact of patient-physician alliance on trust following an adverse event.
Patient Educ Couns. 2019;102(7):1342-1349. doi:10.1016/j.pec.2019.02.015.
https://psnet.ahrq.gov/issue/impact-patient-physi…
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psnet.ahrq.gov/node/38270/psn-pdf
December 01, 2010 - Improving America's Hospitals: The Joint Commission's
Report on Quality and Safety 2008.
December 1, 2010
Oakbrook Terrace, IL: The Joint Commission; November 2008.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-report-quality-and-safety-2008
The quality of care delivered at US hospita…
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psnet.ahrq.gov/node/46472/psn-pdf
August 20, 2018 - Wide variation and overprescription of opioids after
elective surgery.
August 20, 2018
Thiels CA, Anderson SS, Ubl DS, et al. Wide Variation and Overprescription of Opioids After Elective
Surgery. Ann Surg. 2017;266(4):564-573. doi:10.1097/SLA.0000000000002365.
https://psnet.ahrq.gov/issue/wide-variation-and-overp…
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psnet.ahrq.gov/node/40394/psn-pdf
January 01, 2019 - Partnership for Patients.
October 6, 2016
Washington, DC: US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/partnership-patients
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to
decrease preventable harm in United States hospitals.…
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psnet.ahrq.gov/node/44461/psn-pdf
June 21, 2016 - Outcomes of daytime procedures performed by attending
surgeons after night work.
June 21, 2016
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending
Surgeons after Night Work. N Engl J Med. 2015;373(9):845-53. doi:10.1056/NEJMsa1415994.
https://psnet.ahrq.gov/issue/outcom…
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psnet.ahrq.gov/node/74179/psn-pdf
January 01, 2022 - Establishing a multidisciplinary taskforce to improve
anticoagulation safety at a large health system.
December 12, 2021
Attia E, Fuentes A, Vassallo M, et al. Establishing a multidisciplinary taskforce to improve anticoagulation
safety at a large health system. Am J Health Syst Pharm. 2022;79(4):297-305. doi:10.10…
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psnet.ahrq.gov/node/42250/psn-pdf
June 03, 2013 - A long-term follow-up evaluation of electronic health
record prescribing safety.
June 3, 2013
Abramson EL, Malhotra S, Osorio N, et al. A long-term follow-up evaluation of electronic health record
prescribing safety. J Am Med Inform Assoc. 2013;20(e1):e52-8. doi:10.1136/amiajnl-2012-001328.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/845651/psn-pdf
November 17, 2016 - Variability in diagnostic error rates of 10 MRI centers
performing lumbar spine MRI examinations on the same
patient within a 3-week period.
November 17, 2016
Herzog R, Elgort DR, Flanders AE, et al. Variability in diagnostic error rates of 10 MRI centers performing
lumbar spine MRI examinations on the same patien…
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psnet.ahrq.gov/node/46756/psn-pdf
May 09, 2018 - Using a modified A3 lean framework to identify ways to
increase students' reporting of mistreatment behaviors.
May 9, 2018
Ross PT, Abdoler E, Flygt LA, et al. Using a Modified A3 Lean Framework to Identify Ways to Increase
Students' Reporting of Mistreatment Behaviors. Acad Med. 2018;93(4):606-611.
doi:10.1097/AC…
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - Resident fatigue: is there a patient safety issue?
January 6, 2010
Mitchell CD, Mooty CR, Dunn EL, et al. Resident fatigue: is there a patient safety issue? Am J Surg.
2009;198(6):811-6. doi:10.1016/j.amjsurg.2009.04.028.
https://psnet.ahrq.gov/issue/resident-fatigue-there-patient-safety-issue
Regulations limiting…
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psnet.ahrq.gov/node/842763/psn-pdf
January 18, 2023 - Implementation of peer messengers to deliver feedback:
an observational study to promote professionalism in
nursing.
January 18, 2023
Baldwin CA, Hanrahan K, Edmonds SW, et al. Implementation of peer messengers to deliver feedback: an
observational study to promote professionalism in nursing. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/36003/psn-pdf
March 28, 2011 - The "To Err Is Human Report" and the patient safety
literature.
March 28, 2011
Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature.
Qual Saf Health Care. 2006;15(3):174-8.
https://psnet.ahrq.gov/issue/err-human-report-and-patient-safety-literature
This study …
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psnet.ahrq.gov/node/35436/psn-pdf
September 15, 2009 - Hospital nurse staffing and patient mortality, emotional
exhaustion, and job dissatisfaction.
September 15, 2009
Halm M, Peterson M, Kandels M, et al. Hospital nurse staffing and patient mortality, emotional exhaustion,
and job dissatisfaction. Clin Nurse Spec. 2005;19(5):241-254.
https://psnet.ahrq.gov/issue/hosp…