-
psnet.ahrq.gov/node/41313/psn-pdf
January 18, 2017 - Lucian Leape calls for institutions to establish full disclosure, apology, and
compensation policies
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psnet.ahrq.gov/node/38309/psn-pdf
December 23, 2016 - of adverse events associated with information technology and gives detailed recommendations
for how institutions
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psnet.ahrq.gov/node/46009/psn-pdf
September 13, 2017 - skin integrity and fall risk were consistently assessed, but there was
significant variability across institutions
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psnet.ahrq.gov/node/40702/psn-pdf
October 16, 2012 - a diagnostic error, the authors discuss how collective
accountability would require clinicians and institutions
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psnet.ahrq.gov/node/42980/psn-pdf
February 17, 2017 - safety culture,
and establishment of standard metrics to document and benchmark disclosure across institutions
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psnet.ahrq.gov/node/45451/psn-pdf
October 05, 2016 - a survey for patients to provide feedback on safety issues about care
transfers between different institutions
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - HK: We are at the point where we need to find some institutions willing to test this—I firmly believe … that it
will pay dividends for the patients and the institutions. … For the future, we need to create the means by
which consortia of institutions can come together and … If 10 institutions are willing to work together and could
collectively achieve a gain, then they could … We need to find ways for more rapid-cycle learning that can be
tried in a group of institutions and
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psnet.ahrq.gov/issue/ounce-prevention-reduce-errors-hospitals-prescribe-innovative-designs
December 13, 2006 - reports on innovations implemented at a Wisconsin hospital to improve patient safety and how other institutions
-
psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessmentr-antithrombotic-therapy-hospitals
June 07, 2017 - This tool provides institutions with the capacity to assess use of antithrombotic agents, submit data
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psnet.ahrq.gov/issue/how-can-we-save-next-victim
January 23, 2008 - and tells the stories of several victims of tragic medical errors, including steps that providers and institutions
-
psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
February 03, 2021 - these principles to enhance understanding of serious adverse events reported among collaborating institutions
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psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-errors-role-pharmacovigilance-centres
May 18, 2022 - information about incident reporting of medication errors and learning from these events to support these institutions
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psnet.ahrq.gov/issue/electronic-health-record-use-and-quality-ambulatory-care-united-states
May 31, 2023 - for this finding, including the possibility that EHRs were not implemented as fully as at benchmark institutions
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psnet.ahrq.gov/issue/diffusing-aviation-innovations-hospital-netherlands
August 12, 2020 - The authors provide an analysis framework for the diffusion efforts and provide recommendations for institutions
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psnet.ahrq.gov/issue/improving-standardization-paging-communication-using-quality-improvement-methodology
September 23, 2020 - The authors call for institutions to consider standardizing their paging communication.
-
psnet.ahrq.gov/issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
June 15, 2022 - and identified latent safety threats (including related to the use of cognitive aids) at several institutions
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psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
February 01, 2023 - coordinators , designating space for pediatric patients when possible, and collaborating with pediatric institutions
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
March 29, 2023 - This protection helps encourage institutions and individuals to more freely report incidents, concerns
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psnet.ahrq.gov/node/37562/psn-pdf
June 14, 2011 - should focus at the level of the health care system to prevent the
inefficiencies of having individual institutions
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psnet.ahrq.gov/node/45710/psn-pdf
December 22, 2017 - our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-
patient-safety
Root cause analysis (RCA) is a process frequently employed by health care institutions