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psnet.ahrq.gov/issue/innovations-improve-patient-safety
May 25, 2016 - Book/Report
Innovations to improve patient safety.
Citation Text:
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
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psnet.ahrq.gov/perspectives
May 01, 2021 - Perspectives on Safety
Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
Pod…
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psnet.ahrq.gov/issue/impact-medical-mistakes-navigating-work-family-boundaries-physicians-and-their-families
January 23, 2019 - Study
Impact of medical mistakes: navigating work–family boundaries for physicians and their families.
Citation Text:
Petronio S.
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psnet.ahrq.gov/issue/use-bar-code-technology-medication-administration
January 23, 2019 - Commentary
The use of bar code technology in medication administration.
Citation Text:
McRoberts S.
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March 6, 2005
McRober…
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psnet.ahrq.gov/issue/cpoe-not-first-step-toward-patient-safety
March 02, 2016 - Newspaper/Magazine Article
CPOE: not the first step toward patient safety.
Citation Text:
Kremsdorf R
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March 6, 2005
Kremsdo…
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psnet.ahrq.gov/issue/surgical-mistakes-persist-bay-state-still-tiny-fraction-total-procedures
September 10, 2014 - Newspaper/Magazine Article
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Citation Text:
Kowalczyk L.
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psnet.ahrq.gov/issue/mandatory-error-reporting-discourages-disclosure-information
October 26, 2011 - Newspaper/Magazine Article
Mandatory error reporting discourages disclosure of information.
Citation Text:
Tokarski C
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April …
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psnet.ahrq.gov/issue/state-nurse-error-caused-death
May 10, 2006 - Newspaper/Magazine Article
State: nurse error caused death.
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August 2, 2006
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This article reports on a fe…
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psnet.ahrq.gov/issue/how-human-factors-lead-medical-device-adverse-events
February 10, 2021 - Commentary
How human factors lead to medical device adverse events.
Citation Text:
Rich S.
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June 11, 2008
Rich S.
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/node/33741/psn-pdf
November 01, 2012 - The Evidence-Based Physical Examination as a Patient
Safety Practice
November 1, 2012
McGee S. The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
Perspective
Near the end of hi…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case February 2006
Lost in Transition
Source and Credits
This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Christopher Beach, MD; Northwe…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Building Systems Citizenship in Health Professions
Education: The Continued Call for Health Systems
Science Curricula
February 1, 2019
Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call
for Health Systems Science Curricula. PSNet [internet]. 2019.
https://psnet.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - Digital Health Literacy
Citation Text:
Seidel E, Cortes T, Chong C. Digital Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Annual Perspective
Patient Safety and Opioid Medications
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016
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Citation Text:
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…