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psnet.ahrq.gov/node/73331/psn-pdf
May 26, 2021 - Cancer diagnoses delayed among prisoners in
Washington state.
May 26, 2021
Medscape Medical News. May 12, 2021.
https://psnet.ahrq.gov/issue/cancer-diagnoses-delayed-among-prisoners-washington-state
Delays and mistakes in health care for distinct patient populations hold improvement lessons for the
broader system…
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psnet.ahrq.gov/node/36792/psn-pdf
August 26, 2011 - Adaptive regulation or governmentality: patient safety
and the changing regulation of medicine.
August 26, 2011
Waring J. Adaptive regulation or governmentality: patient safety and the changing regulation of medicine.
Sociol Health Illn. 2007;29(2):163-79.
https://psnet.ahrq.gov/issue/adaptive-regulation-or-govern…
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psnet.ahrq.gov/node/46332/psn-pdf
September 24, 2017 - Sharing the process of diagnostic decision making.
September 24, 2017
Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med.
2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929.
https://psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making
Improving diagnosis has …
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psnet.ahrq.gov/node/44223/psn-pdf
November 22, 2016 - Patient Safety and Incident Management Toolkit.
November 22, 2016
Edmonton, AB: Canadian Patient Safety Institute. June 2015.
https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit
Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-
compone…
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psnet.ahrq.gov/node/43936/psn-pdf
December 04, 2015 - Exploring the Potential Use of Safety Cases in Health
Care.
December 4, 2015
Safety Cases Working Group. London, UK: Health Foundation; 2015.
https://psnet.ahrq.gov/issue/exploring-potential-use-safety-cases-health-care
This report describes a consensus-building initiative in the United Kingdom seeking to determin…
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psnet.ahrq.gov/node/855435/psn-pdf
November 15, 2023 - Technology, Education and Safety
November 15, 2023
Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.
https://psnet.ahrq.gov/issue/technology-education-and-safety-2
Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of
reviews illustrates relationsh…
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psnet.ahrq.gov/node/36654/psn-pdf
June 29, 2011 - The moderate success of quality of care improvement
efforts: three observations on the situation.
June 29, 2011
Katz-Navon T, Naveh E, Stern Z. The moderate success of quality of care improvement efforts: three
observations on the situation. International Journal for Quality in Health Care. 2006;19(1).
doi:10.1093…
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psnet.ahrq.gov/node/39690/psn-pdf
July 21, 2010 - Characteristics of quality and patient safety curricula in
major teaching hospitals.
July 21, 2010
Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major
teaching hospitals. Am J Med Qual. 2010;25(4):305-11. doi:10.1177/1062860610367677.
https://psnet.ahrq.gov/issue/ch…
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psnet.ahrq.gov/node/35292/psn-pdf
June 27, 2011 - The DNA damage response and patient safety: engaging
our molecular biology-oriented colleagues.
June 27, 2011
Pukk K, Aron DC. The DNA damage response and patient safety: engaging our molecular biology-oriented
colleagues. International Journal for Quality in Health Care. 2005;17(4). doi:10.1093/intqhc/mzi041.
htt…
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psnet.ahrq.gov/node/47056/psn-pdf
April 20, 2022 - Healthcare Simulation Week.
April 20, 2022
Society for Simulation in Healthcare.
https://psnet.ahrq.gov/issue/healthcare-simulation-week
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance
individual and team performance. This website provides promotional materials f…
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - That's something that medicine has learned and could continue to learn from, that any member of the team … July 24, 2010
What have we learned about interventions to reduce medical errors?
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - The essential difference is that it treats the physician as the "learned intermediary" (to borrow a phrase … diagnosis-specific knowledge on how does one investigate, how does one treat, what are the lessons learned
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psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
January 01, 2006 - RW: How has your training program evolved and what lessons have you learned as you've actually gone … Certainly there are some technical things that could be learned, but because of the current state of
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psnet.ahrq.gov/node/50641/psn-pdf
November 06, 2019 - Taking Action Against Clinician Burnout: A Systems
Approach to Professional Well-Being.
November 6, 2019
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2019. ISBN: 9780309495509.
https://psnet.ahrq.gov/issue/taking-action-against-clinician-burnout-systems-a…
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psnet.ahrq.gov/node/45367/psn-pdf
September 28, 2016 - How PSOs Help Health Care Organizations Improve
Patient Safety Culture.
September 28, 2016
Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF.
https://psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture
Patient safety organization…
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psnet.ahrq.gov/node/34951/psn-pdf
February 28, 2011 - Ambiguity and workarounds as contributors to medical
error.
February 28, 2011
Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med.
2005;142(8):627-630.
https://psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
This commentary discusses the ro…
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psnet.ahrq.gov/node/47847/psn-pdf
July 10, 2024 - CHPSO Annual Reports.
July 10, 2024
California Hospital Patient Safety Organization: Sacramento, CA; 2024.
https://psnet.ahrq.gov/issue/chpso-2019-annual-report
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490
members. This report highlights 2023 trends, activit…
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psnet.ahrq.gov/node/43432/psn-pdf
October 01, 2014 - The ethical imperative to think about thinking.
October 1, 2014
Stark M, Fins JJ. The ethical imperative to think about thinking - diagnostics, metacognition, and medical
professionalism. Camb Q Healthc Ethics. 2014;23(4):386-96. doi:10.1017/S0963180114000061.
https://psnet.ahrq.gov/issue/ethical-imperative-think-a…
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psnet.ahrq.gov/node/36835/psn-pdf
July 08, 2008 - Predicting future staffing needs at teaching hospitals: use
of an analytical program with multiple variables.
July 8, 2008
Mitchell CC, Ashley SW, Zinner MJ, et al. Predicting future staffing needs at teaching hospitals: use of an
analytical program with multiple variables. Arch Surg. 2007;142(4):329-34.
https://p…
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psnet.ahrq.gov/node/38225/psn-pdf
February 16, 2011 - Changing conversations: teaching safety and quality in
residency training.
February 16, 2011
Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency
training. Acad Med. 2008;83(11):1080-7. doi:10.1097/ACM.0b013e31818927f8.
https://psnet.ahrq.gov/issue/changing-convers…