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www.ahrq.gov/topics/burnout.html
Topic: Burnout
Burnout is a serious and growing problem in many healthcare settings. Burnout can increase worker turnover and reduce quality of care, leading to lower patient satisfaction and patient safety as well as higher costs of care. AHRQ supports a wide range of projects to assess and reduce burnout among clin…
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psnet.ahrq.gov/node/38202/psn-pdf
November 12, 2008 - The tipping point: the relationship between volume and
patient harm.
November 12, 2008
Pedroja AT. The tipping point: the relationship between volume and patient harm. Am J Med Qual.
2008;23(5):336-41. doi:10.1177/1062860608320628.
https://psnet.ahrq.gov/issue/tipping-point-relationship-between-volume-and-patient-…
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psnet.ahrq.gov/node/39448/psn-pdf
May 20, 2015 - A Patient Safety Handbook for Ambulatory Care
Providers.
May 20, 2015
Oak Brook, IL: Joint Commission Resources; 2009. ISBN: 9781599403670.
https://psnet.ahrq.gov/issue/patient-safety-handbook-ambulatory-care-providers
This guide offers tools and strategies to ensure that care in the ambulatory setting is safely p…
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psnet.ahrq.gov/node/35833/psn-pdf
July 23, 2010 - Medication administration errors: understanding the
issues.
July 23, 2010
McBride-Henry K, Foureur M. Medication administration errors: understanding the issues. Aust J Adv Nurs.
2006;23(3):33-41.
https://psnet.ahrq.gov/issue/medication-administration-errors-understanding-issues
The authors review the literature …
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psnet.ahrq.gov/node/36587/psn-pdf
January 14, 2011 - The value of inking breast cores to reduce specimen mix-
up.
January 14, 2011
Renshaw AA, Kish R, Gould EW. The value of inking breast cores to reduce specimen mix-up. Am J Clin
Pathol. 2007;127(2):271-2.
https://psnet.ahrq.gov/issue/value-inking-breast-cores-reduce-specimen-mix
The authors describe a tissue spec…
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psnet.ahrq.gov/node/43267/psn-pdf
June 11, 2014 - The PROTECT Initiative: Advancing Children's Medication
Safety.
June 11, 2014
US Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/protect-initiative-advancing-childrens-medication-safety
This Web site offers resources related to a collaborative involving public health agencies, private
org…
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psnet.ahrq.gov/node/35033/psn-pdf
May 18, 2005 - Medical errors still claiming many lives.
May 18, 2005
Weise E. USA Today. May 18, 2005.
https://psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives
This article highlights a commentary published in JAMA by two leading experts in patient safety
which summarizes the progress made since publication of the …
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psnet.ahrq.gov/node/41665/psn-pdf
September 12, 2012 - Risk factors associated with incorrect surgical counts.
September 12, 2012
Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272-84.
doi:10.1016/j.aorn.2012.06.012.
https://psnet.ahrq.gov/issue/risk-factors-associated-incorrect-surgical-counts
This study explored factors leadin…
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psnet.ahrq.gov/node/38978/psn-pdf
January 04, 2010 - Unintended exposure in radiotherapy: identification of
prominent causes.
January 4, 2010
Boadu M, Rehani MM. Unintended exposure in radiotherapy: identification of prominent causes. Radiother
Oncol. 2009;93(3):609-17. doi:10.1016/j.radonc.2009.08.044.
https://psnet.ahrq.gov/issue/unintended-exposure-radiotherapy-i…
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psnet.ahrq.gov/node/40718/psn-pdf
August 31, 2011 - Misinformation in the medical literature: what role do
error and fraud play?
August 31, 2011
Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics.
2011;37(8):498-503. doi:10.1136/jme.2010.041830.
https://psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-…
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psnet.ahrq.gov/node/38979/psn-pdf
October 14, 2009 - Active learning: when is more better? The case of
resident physicians' medical errors.
October 14, 2009
Katz-Navon T; Naveh E; Stern Z.
https://psnet.ahrq.gov/issue/active-learning-when-more-better-case-resident-physicians-medical-errors
Establishing an active learning climate, in which resident physicians are enc…
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psnet.ahrq.gov/node/37851/psn-pdf
June 18, 2008 - Medical errors affecting the pediatric intensive care
patient: incidence, identification, and practical solutions.
June 18, 2008
Nichter MA.
https://psnet.ahrq.gov/issue/medical-errors-affecting-pediatric-intensive-care-patient-incidence-
identification-and
This article reviews how the complexity of care in the p…
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psnet.ahrq.gov/node/36960/psn-pdf
September 12, 2011 - Profiles in patient safety: a "perfect storm" in the
emergency department.
September 12, 2011
Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: A "perfect storm" in the emergency
department. Acad Emerg Med. 2007;14(8):743-9.
https://psnet.ahrq.gov/issue/profiles-patient-safety-perfect-storm-emergency-…
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psnet.ahrq.gov/node/41060/psn-pdf
September 06, 2013 - Flaws in clinical reasoning: a common cause of
diagnostic error.
September 6, 2013
Wellbery C. Flaws in clinical reasoning: a common cause of diagnostic error. Am Fam Physician.
2011;84(9):1042-8.
https://psnet.ahrq.gov/issue/flaws-clinical-reasoning-common-cause-diagnostic-error
Through an illustrative case repo…
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psnet.ahrq.gov/node/42799/psn-pdf
December 04, 2013 - All can be lost: the risk of putting our knowledge in the
hands of machines.
December 4, 2013
Carr N. The Atlantic. November 2013.
https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines
Increasingly, computerized systems are performing more complex tasks in high-risk industries like…
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psnet.ahrq.gov/node/44632/psn-pdf
March 24, 2016 - Clash in the name of care.
March 24, 2016
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
https://psnet.ahrq.gov/issue/clash-name-care
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news
article explores the practice of overlapping p…
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psnet.ahrq.gov/node/38931/psn-pdf
April 18, 2011 - Patient safety in intensive care medicine: the Declaration
of Vienna.
April 18, 2011
Moreno RP, Rhodes A, Donchin Y. Patient safety in intensive care medicine: the Declaration of Vienna.
Intensive Care Med. 2009;35(10). doi:10.1007/s00134-009-1621-2.
https://psnet.ahrq.gov/issue/patient-safety-intensive-care-medic…
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psnet.ahrq.gov/node/867769/psn-pdf
March 12, 2025 - Lessons from Event Reports.
March 12, 2025
Lessons from Event Reports. Patient Safety Authority.
https://psnet.ahrq.gov/issue/lessons-event-reports
Small successes can inform and motivate actions leading to sustainable, evidence-based change. This
searchable collection of projects initiated in response to event re…
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psnet.ahrq.gov/node/34958/psn-pdf
June 14, 2011 - Patient safety in an interprofessional learning
environment.
June 14, 2011
Horsburgh M, Merry A, Seddon M. Patient safety in an interprofessional learning environment. Med Educ.
2005;39(5):512-3.
https://psnet.ahrq.gov/issue/patient-safety-interprofessional-learning-environment
The authors discuss a patient safet…
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - Guidelines for Design and Construction.
February 5, 2019
St Louis, Missouri; Facilities Guidelines Institute; 2018.
https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design changes, such as the adoption of private rooms to reduce
medical error, interruptions, and hosp…