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psnet.ahrq.gov/issue/aging-physician-and-medical-profession-review
May 27, 2010 - Exploring how to approach assessments of the aging physician , this review suggests that health care institutions
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psnet.ahrq.gov/issue/speak-addressing-paradox-plaguing-patient-centered-care
October 17, 2018 - have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions
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psnet.ahrq.gov/issue/racial-bias-among-emergency-providers-strategies-mitigate-its-adverse-effects
January 12, 2011 - The authors propose strategies for educators and institutions to combat implicit bias including self-awareness
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psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety
July 14, 2010 - This AHRQ–funded study investigated whether institutions implementing care management achieved improvements
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psnet.ahrq.gov/issue/safety-overlapping-inpatient-orthopaedic-surgery-multicenter-study
April 24, 2018 - This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found
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psnet.ahrq.gov/issue/measuring-adverse-events-hospitalized-patients-administrative-method-measuring-harm
December 17, 2014 - enough for internal quality improvement purposes, but the tool is insufficient to compare harm across institutions
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psnet.ahrq.gov/issue/advising-patients-about-patient-safety-current-initiatives-risk-shifting-responsibility
May 20, 2015 - recommended actions, and that some of the shifting of responsibility for safety from providers and/or institutions
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psnet.ahrq.gov/issue/reconciling-medications-admission-safe-practice-recommendations-and-implementation-strategies
January 02, 2017 - Overall, the authors provide a practical, step-by-step experiential guide for institutions and individuals
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psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
May 25, 2016 - Some pioneering institutions, such as the University of Michigan Health System, began implementing an
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions
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psnet.ahrq.gov/issue/ashamed-admit-it-owning-medical-error
April 03, 2019 - Disclosing medical errors to patients: a challenge for health care professionals and institutions
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psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors
January 11, 2023 - Paper- and computer-based workarounds to electronic health record use at three benchmark institutions
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - to University Healthsystem Consortium (UHC) use these PSIs to rate the quality of care at different institutions … coding has been in place for more than a decade, found that patterns in POA coding differed across institutions … Variation in ICD-9-CM Coding and Limitations of Reporting
Variation is not only evident across institutions … Today, however, the variability of thoroughness of reporting and accuracy of coding across institutions … That was appropriate when the adverse events just happened and they cost institutions more money to take
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
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 … Many institutions have developed multipronged approaches to enhancing postdischarge care.
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - Outline steps providers and institutions can take to decrease the risk of complications with colonoscopy … Institutions can also encourage development of protocols to aid clinicians in managing complicated conditions … Institutions face significant challenges in ensuring that their providers are competent to perform the … Institutions should, whenever possible, use objective criteria and direct observation to assess competence
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - The sequences included in fast MRI vary depending on the technology and resources available to institutions … Given the high stakes involved, some institutions perform independent double-reads of skeletal surveys … When this evaluation occurs overnight, it may not be feasible for many institutions to have an attending … If an experienced radiologist is not available overnight, institutions should establish clear discharge
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psnet.ahrq.gov/issue/new-persistent-opioid-use-after-postoperative-intensive-care-us-veterans
July 10, 2024 - Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions
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psnet.ahrq.gov/issue/effectiveness-computerized-provider-order-entry-dose-range-checking-prescribing-errors
October 23, 2024 - electronic adverse event identification, classification, and corrective actions across academic pediatric institutions
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psnet.ahrq.gov/issue/efficacy-incident-reporting-system-cellular-pathology-practical-experience
August 21, 2024 - College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions
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psnet.ahrq.gov/issue/learning-others-legal-aspects-sharing-patient-safety-data-using-provider-consortia
May 04, 2019 - July 14, 2010
Barriers to implementation of patient safety systems in healthcare institutions