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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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www.ahrq.gov/nursing-home/resources/what-matters-toolkit.html
February 01, 2021 - "What Matters" to Older Adults?
Resource: "What Matters" to Older Adults? (PDF, 2.17 MB)
The toolkit is intended to serve as a resource for multidisciplinary care teams, including, but not limited to physicians, nurses, physician assistants, medical assistants, social workers, chaplains, nurse navigators, …
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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-…
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www.ahrq.gov/evidencenow/heart-health/aspirin/stroke.html
September 01, 2018 - Aspirin, Heart Disease, and Stroke Pamphlet: American Stroke Association
Resource title: Aspirin, Heart Disease, and Stroke .
Resource description: This patient education booklet explains how heart attack and stroke happen, and the potential risks and benefits of aspirin in prevention and treatment.
Docu…
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psnet.ahrq.gov/node/40646/psn-pdf
July 27, 2011 - Engineering a Learning Healthcare System: A Look at the
Future: Workshop Summary.
July 27, 2011
Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of
Engineering. Washington, DC: The National Academies Press; 2011. ISBN: 9780309120647.
https://psnet.ahrq.gov/issue/engineering…
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - Are We Getting Better at Measuring Patient Safety?
November 1, 2010
Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
Perspective
The past decade has witnessed unprecedented interest in patient safe…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6o.html
June 01, 2014 - Care Coordination Measures Atlas Update
Chapter 6. Measure Maps and Profiles (continued, 16)
Previous Page Next Page
Table of Contents
Care Coordination Measures Atlas Update
Chapter 1: Background
Chapter 2. What is Care Coordination?
Chapter 3. Care Coordination Measurement Framework
Chapte…
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
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www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - Implementation Guide for the CANDOR Process
Communication and Optimal Resolution Toolkit
Purpose: The Toolkit Implementation Guide is a reference for organizational leaders who are committed to improving their response to unexpected patient harm events. The guide describes the CANDOR process, implementatio…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4b
Selected Best Practices and Suggestions for Improvement
PDI 02: Pressure Ulcer
Why focus on pressure ulcers in children?
• Although childre…