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psnet.ahrq.gov/issue/fdasia-health-it-report-proposed-strategy-and-recommendations-risk-based-framework
June 29, 2016 - Government Resource
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.
Citation Text:
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. Washington, DC: Office of the National Coordinator for Health Informati…
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psnet.ahrq.gov/issue/out-crisis
March 06, 2005 - Book/Report
Classic
Out of the Crisis.
Citation Text:
Out of the Crisis. Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. ISBN: 9780911379013.
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psnet.ahrq.gov/issue/adverse-safety-events-emergency-medical-services-care-children-out-hospital-cardiac-arrest
May 18, 2022 - Study
Adverse safety events in emergency medical services care of children with out-of-hospital cardiac arrest.
Citation Text:
Eriksson CO, Bahr N, Meckler G, et al. Adverse safety events in emergency medical services care of children with out-of-hospital cardiac arrest. JAMA Netw Open. …
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psnet.ahrq.gov/issue/opioid-guidelines-common-dental-surgical-procedures-multidisciplinary-panel-consensus
April 28, 2021 - Organizational Policy/Guidelines
Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.
Citation Text:
Farooqi OA, Bruhn WE, Lecholop MK, et al. Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus. Int J Oral…
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psnet.ahrq.gov/issue/enhancing-patient-safety-integrating-ethical-dimensions-critical-incident-reporting-systems
January 12, 2022 - Commentary
Enhancing patient safety by integrating ethical dimensions to critical incident reporting systems.
Citation Text:
Wehkamp K, Kuhn E, Petzina R, et al. Enhancing patient safety by integrating ethical dimensions to Critical Incident Reporting Systems. BMC Med Ethics. 2021;22(1):…
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psnet.ahrq.gov/issue/missed-nursing-care-during-covid-19-pandemic-comparative-observational-study
June 22, 2022 - Study
Missed nursing care during the COVID-19 pandemic: a comparative observational study.
Citation Text:
von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. Missed nursing care during the COVID‐19 pandemic: a comparative observational study. J Nurs Manag. 2021;29(8):2343-2352. doi:10.1111…
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psnet.ahrq.gov/issue/enhancing-implementation-i-pass-handoff-tool-using-provider-handoff-task-force-comprehensive
March 09, 2022 - Study
Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a Comprehensive Cancer Center.
Citation Text:
Franco Vega MC, Ait Aiss M, George M, et al. Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a Compreh…
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psnet.ahrq.gov/issue/creation-root-cause-analysis-and-action-rca2-standard-work-multidisciplinary-team-prevent
October 19, 2022 - Study
Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture.
Citation Text:
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work by a multidis…
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psnet.ahrq.gov/issue/data-driven-quality-improvement-culture-change-and-high-reliability-journey-special-hospital
March 24, 2021 - Commentary
Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.
Citation Text:
Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high relia…
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psnet.ahrq.gov/issue/primary-care-teams-reported-actions-improve-medication-safety-qualitative-study-insights-high
July 06, 2022 - Study
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
Citation Text:
Young RA, Gurses AP, Fulda KG, et al. Primary care teams’ reported actions to improve medication safety: a qualitative study with insi…
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psnet.ahrq.gov/issue/covid-19-pandemic-patient-safety-new-spring-telemedicine-or-boomerang-effect
April 13, 2022 - Commentary
From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?
Citation Text:
De Micco F, Fineschi V, Banfi G, et al. From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect? Front Med (Lausanne). 2022;9…
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psnet.ahrq.gov/issue/streamlining-care-crisis-rapid-creation-and-implementation-digital-support-tool-covid-19
October 21, 2020 - Commentary
Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.
Citation Text:
Stark N, Kerrissey M, Grade M, et al. Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19. West J Emerg Med. …
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psnet.ahrq.gov/issue/nurse-work-environment-and-its-impact-reasons-missed-care-safety-climate-and-job-satisfaction
April 14, 2021 - Study
Nurse work environment and its impact on reasons for missed care, safety climate, and job satisfaction: a cross-sectional study.
Citation Text:
Dutra CK dos R, Guirardello E de B. Nurse work environment and its impact on reasons for missed care, safety climate, and job satisfaction…
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/node/46349/psn-pdf
August 16, 2017 - Health Literacy Tools for Providers of Medication Therapy
Management.
August 16, 2017
Rockville, MD: Agency for Healthcare Research and Quality; July 2017.
https://psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management
Health literacy is important for effective care communications and s…
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - Respectful Management of Serious Clinical Adverse
Events. Second Edition.
September 19, 2016
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement;
2011.
https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
This white paper e…
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - SPOTLIGHT CASE
Treatment Challenges After Discharge
Citation Text:
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/issue/unsafe-design-infusion-task-reallocation-and-safety-perceptions-us-hospitals
December 21, 2017 - Study
Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.
Citation Text:
Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/…
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psnet.ahrq.gov/issue/what-went-right-lessons-intensivist-crew-us-airways-flight-1549
February 23, 2009 - Commentary
What went right: lessons for the intensivist from the crew of US Airways Flight 1549.
Citation Text:
Eisen LA, Savel RH. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest. 2009;136(3):910-917. doi:10.1378/chest.09-0377.
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psnet.ahrq.gov/issue/engagement-leadership-quality-improvement-initiatives-executive-quality-improvement-survey
October 04, 2006 - Study
Engagement of leadership in quality improvement initiatives: executive quality improvement survey results.
Citation Text:
Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. Vaughn T, Koepke M, Kroch E, et al. J Patient Saf…