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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - Update on Safety Culture
Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013
View more articles from the same authors.
Citation Text:
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - PowerPoint Presentation
Spotlight
Monitoring Fetal Health
1
This presentation is based on the January 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.pdf
January 01, 2012 - Information to Help Hospitals Get Started
Information to Help Hospitals Get Started
Guide to Patient and Family Engagement :: 1
How Patient and Family Engagement
Benefits Your Hospital
Patient and family engagement is an area of increasing
importance for hospitals. Not only is engaging patients
and families…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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digital.ahrq.gov/sites/default/files/docs/publication/r13hs022817-chen-final-report-2014.pdf
January 01, 2014 - Workshop on Interactive Systems in Healthcare 2013: Bridging Communities - Final Report
WORKSHOP ON INTERACTIVE SYSTEMS IN
HEALTHCARE (WISH) 2013: BRIDGING COMMUNITIES
Yunan Chen MD, P…
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-workgroup-meeting-notes-apr2025.pdf
August 01, 2025 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, April 18, 2025
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
April 18, 2025, 10 AM–Noon
1
Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on
Appropriation…
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www.ahrq.gov/ncepcr/reports/cost-guide/collection-tools.html
February 01, 2017 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report
Appendix B. Example Data Collection Tools
Previous Page Next Page
Table of Contents
Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report
Background
A Practical Guide…
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www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
January 01, 2024 - Potential confounders will include patient demographics, types and level of providers,
institutional … There was no institutional or department-specific standard approach to
VTE diagnosis used in this institution
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - This ensures that provider, and often even institutional, identities are shielded.
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effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
June 01, 2013 - AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Crosscutting Interventions and Programs
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov
Contract No. HHS…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/behavioral-counseling-interventions-evidence-based-approach
March 04, 2021 - Behavioral Counseling Interventions: An Evidence-based Approach
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Table of Contents Preface Abstract Introduction Background Rationale for Behavioral Counseling Interventions i…
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effectivehealthcare.ahrq.gov/sites/default/files/pulmonary-horizon-scan-high-impact-1306.pdf
June 01, 2013 - PULMONARY with "Discussions" in Exec Summary
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 13: Pulmonary Disease, Including Asthma
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither…
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effectivehealthcare.ahrq.gov/sites/default/files/pulmonary_hi_impact.pdf
April 01, 2012 - PULMONARY with "Discussions" in Exec Summary
AHRQ Healthcare Horizon Scanning System – Potential High
Impact Interventions Report
Priority Area 13: Pulmonary Disease including Asthma
Potential High Impact Interventions Report
Prepared for:
Agency for Healthcare Research and Quality
U.S. Departme…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…