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psnet.ahrq.gov/node/73454/psn-pdf
June 30, 2021 - Poor physician-patient communication and medical error.
June 30, 2021
Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759.
https://psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error
Communication failures are primary threat to safe care. This comment…
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psnet.ahrq.gov/node/45659/psn-pdf
November 16, 2016 - Misdiagnoses: a hidden risk of genetic testing.
November 16, 2016
Howard J. CNN. October 31, 2016.
https://psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing
Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary
care. This news article reports on the un…
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psnet.ahrq.gov/node/34882/psn-pdf
February 28, 2011 - Fumbled handoffs: one dropped ball after another.
February 28, 2011
Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358.
https://psnet.ahrq.gov/issue/fumbled-handoffs-one-dropped-ball-after-another
This case study discusses the chain of events surrounding the delayed dia…
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psnet.ahrq.gov/node/44964/psn-pdf
March 09, 2016 - EHRs in the ER: as doctors adapt, concerns emerge
about medical errors.
March 9, 2016
Luthra S.
https://psnet.ahrq.gov/issue/ehrs-er-doctors-adapt-concerns-emerge-about-medical-errors
Many emergency departments have recently implemented electronic health records, which has introduced
new safety hazards. This news…
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psnet.ahrq.gov/node/47070/psn-pdf
June 25, 2018 - Time out—charting a path for improving performance
measurement.
June 25, 2018
MacLean CH, Kerr EA, Qaseem A. Time Out - Charting a Path for Improving Performance Measurement. N
Engl J Med. 2018;378(19):1757-1761. doi:10.1056/NEJMp1802595.
https://psnet.ahrq.gov/issue/time-out-charting-path-improving-performance-me…
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psnet.ahrq.gov/node/37527/psn-pdf
August 24, 2015 - MEDMARX Data Report: A Report on the Relationship of
Drug Names and Medication Errors in Response to the
Institute of Medicine's Call to Action (2003-2006 Findings
and Trends 2002-2006).
August 24, 2015
Hicks RW, Becker SC, Cousins DD, eds. Rockville, MD: Center for the Advancement of Patient Safety, US
Pharmacop…
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psnet.ahrq.gov/node/34757/psn-pdf
November 18, 2015 - Unity of Mistakes: A Phenomenological Interpretation of
Medical Work.
November 18, 2015
Paget MA. Philadelphia: Temple University Press; 2004.
https://psnet.ahrq.gov/issue/unity-mistakes-phenomenological-interpretation-medical-work
In this often described landmark text on the nature of medical error, Marianne Page…
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psnet.ahrq.gov/node/46527/psn-pdf
March 07, 2018 - When missing a 'zebra' can land you in court.
March 7, 2018
Crane M. Medscape Business of Medicine. February 20, 2018.
https://psnet.ahrq.gov/issue/when-missing-zebra-can-land-you-court
Cognitive biases contribute to missed diagnoses. This article discusses how cognitive biases affect
decision making associated wi…
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psnet.ahrq.gov/node/73576/psn-pdf
August 04, 2021 - The 2020 John M. Eisenberg Patient Safety and Quality
Awards.
August 4, 2021
Jt Comm J Qual Patient Saf. 2021;47(8):463-488.
https://psnet.ahrq.gov/issue/2020-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made significant advancement…
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psnet.ahrq.gov/node/60260/psn-pdf
April 22, 2020 - Joint Statement on Multiple Patients Per Ventilator.
April 22, 2020
The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for
Respiratory Care, American Society of Anesthesiologists, American Association of Critical?Care Nurses,
and American College of Chest Physicians. M…
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psnet.ahrq.gov/node/46233/psn-pdf
September 24, 2017 - Cutting-edge efforts in surgical patient safety.
September 24, 2017
Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719-
720. doi:10.1001/jamasurg.2017.0858.
https://psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
Implementation science examines me…
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psnet.ahrq.gov/node/38339/psn-pdf
January 31, 2011 - Physician autonomy and informed decision making:
finding the balance for patient safety and quality.
January 31, 2011
Mathews SC, Pronovost P. Physician autonomy and informed decision making: finding the balance for
patient safety and quality. JAMA. 2008;300(24):2913-5. doi:10.1001/jama.2008.846.
https://psnet.ahr…
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www.ahrq.gov/evidencenow/projects/urinary/resources/healthy-hearts-nyc-flyer.html
August 01, 2018 - Back to MUI Resources
Healthy Hearts NYC Recruitment Flyer
Resource
Available on the AHRQ website (PDF, 194 KB)
Summary
This practice recruitment flyer from the EvidenceNow Healthy Hearts NYC project is an example of how to present a research study in recruitment materials, i…
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www.ahrq.gov/evidencenow/projects/urinary/resources/healthy-hearts-call-script.html
January 01, 2019 - Back to MUI Resources
HealthyHearts NYC Recruitment Call Script
Resource
Document available on the AHRQ website (PDF, 125 KB).
Summary
This resource is an example of a recruitment phone call script that displays strategies for message framing, responding to “no’s”, eligibilit…
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psnet.ahrq.gov/node/73669/psn-pdf
September 01, 2021 - Infection Prevention Compendium For Long-Term Care
Facilities.
September 1, 2021
Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.
https://psnet.ahrq.gov/issue/infection-prevention-compendium-long-term-care-facilities
Healthcare-associated infections (HAIs) challenge safety in long-te…
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psnet.ahrq.gov/node/41514/psn-pdf
July 02, 2014 - Perspective: beyond counting hours: the importance of
supervision, professionalism, transitions of care, and
workload in residency training.
July 2, 2014
Schumacher D, Slovin SR, Riebschleger MP, et al. Perspective. Academic Medicine. 2012;87(7).
doi:10.1097/acm.0b013e318257d57d.
https://psnet.ahrq.gov/issue/pers…
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psnet.ahrq.gov/node/35913/psn-pdf
February 16, 2011 - Improving oversight of the graduate medical education
enterprise: one institution's strategies and tools.
February 16, 2011
Afrin LB, Arana GW, Medio FJ, et al. Improving Oversight of the Graduate Medical Education Enterprise:
One Institution???s Strategies and Tools. Academic Medicine. 2006;81(5).
doi:10.1097/01.…
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www.ahrq.gov/action-alliance/webinars/workforce-turnover-crisis.html
January 01, 2025 - National Action Alliance Webinar: Resolving Workforce Turnover Crisis
Summary Workforce turnover among nurses and physicians is a growing challenge. This webinar held on December 10, the final part of a series on workforce safety and well-being, discussed the key drivers of nurse turnover, such as burnout, and …
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psnet.ahrq.gov/node/50595/psn-pdf
January 01, 2020 - Clinical reasoning as a core competency.
October 30, 2019
Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med.
2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027.
https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency
Enhancing clinical reasoning skill, particularly amon…
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digital.ahrq.gov/ahrq-funded-projects/advancing-quality-measurement-and-care-improvement-health-information-exchange/final-report
January 01, 2023 - Advancing Quality Measurement and Care Improvement with Health Information Exchange - Final Report
Citation
Shapiro, J. Advancing Quality Measurement and Care Improvement with Health Information Exchange - Final Report. (Prepared by Mount Sinai School of Medicine under Grant No. R01 HS021261). Rockvil…