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psnet.ahrq.gov/node/836833/psn-pdf
March 30, 2022 - As a nurse faces prison for a deadly error, her colleagues
worry: could I be next?
March 30, 2022
Kelman B. Kaiser Health News. March 22, 2022
https://psnet.ahrq.gov/issue/nurse-faces-prison-deadly-error-her-colleagues-worry-could-i-be-next
Criminalization of medical mistakes typifies the blame-focused approach pa…
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psnet.ahrq.gov/node/866358/psn-pdf
July 24, 2024 - To improve health care, focus on fixing systems — not
people.
July 24, 2024
Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people.
Harvard Business Review. July 12, 2024;
https://psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people
While a focus on the…
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psnet.ahrq.gov/node/842774/psn-pdf
January 18, 2023 - ER doctors misdiagnose patients with unusual
symptoms.
January 18, 2023
Abelson R. New York Times. December 15, 2022.
https://psnet.ahrq.gov/issue/er-doctors-misdiagnose-patients-unusual-symptoms
Emergency department safety is challenged by factors such as production pressure, burnout, and
overcrowding. This news…
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psnet.ahrq.gov/node/838083/psn-pdf
September 14, 2022 - A pause in pediatrics: implementation of a pediatric
diagnostic time-out.
September 14, 2022
Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic
time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010.
https://psnet.ahrq.gov/issue/pause-pediatrics-…
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psnet.ahrq.gov/node/40085/psn-pdf
December 15, 2010 - Medication reconciliation in the emergency department:
opportunities for workflow redesign.
December 15, 2010
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for
workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121.
https://psnet.ah…
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www.ahrq.gov/evidencenow/heart-health/smoking/treatment.html
August 01, 2018 - Treating Tobacco Use and Dependence: 2008 Update by HHS Panel
Resource title: Treating Tobacco Use and Dependence: 2008 Update
Resource description: This update to a previous guideline by the Tobacco Use and Dependence Guideline Panel contains strategies and recommendations for effective treatments for tob…
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www.ahrq.gov/priority-populations/publications/richardson-et-al-2020.html
January 01, 2021 - Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease
Pompe disease is a rare condition that is identified in about 1 in 40,000 births. It occurs from a defect in the GAA gene leading to the accumulation of lysosomal glycogen and, depending on the form and severity, can result in c…
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www.ahrq.gov/action-alliance/webinars/safer-guides.html
February 01, 2025 - National Action Alliance Webinar: Engineering Safety Into Practice Through Implementation of the 2025 SAFER Guides
Summary On January 21, 2025, Dean Sittig, Ph.D., and Hardeep Singh, M.D., M.P.H., the authors of the Safety Assurance Factors for EHR Resilience (SAFER) Guides, discussed the development of the lat…
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www.ahrq.gov/evidencenow/projects/urinary/resources/outreach-script-healthy-hearts.html
March 01, 2021 - Back to MUI Resources
Community Health Care Association of New York State Recruitment Outreach Script
Resource
Document available on the AHRQ website (PDF, 169 KB).
Summary
This resource is an example of a recruitment phone call script for conversations with a CMO, CEO or QI …
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psnet.ahrq.gov/node/43527/psn-pdf
September 24, 2014 - The morbidity and mortality conference in PICUs in the
United States: a national survey.
September 24, 2014
Cifra CL, Bembea MM, Fackler JC, et al. The morbidity and mortality conference in PICUs in the United
States: a national survey. Crit Care Med. 2014;42(10):2252-7. doi:10.1097/CCM.0000000000000505.
https://p…
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psnet.ahrq.gov/node/37422/psn-pdf
March 23, 2011 - Educational quality improvement report: outcomes from a
revised morbidity and mortality format that emphasised
patient safety.
March 23, 2011
Bechtold ML, Scott SD, Nelson K, et al. Educational quality improvement report: outcomes from a revised
morbidity and mortality format that emphasised patient safety. Qual S…
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psnet.ahrq.gov/node/39060/psn-pdf
October 28, 2009 - Impact of duty-hour restriction on resident inpatient
teaching.
October 28, 2009
Mazotti LA, Vidyarthi AR, Wachter RM, et al. Impact of duty-hour restriction on resident inpatient teaching.
J Hosp Med. 2009;4(8). doi:10.1002/jhm.448.
https://psnet.ahrq.gov/issue/impact-duty-hour-restriction-resident-inpatient-teac…
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psnet.ahrq.gov/node/42545/psn-pdf
September 04, 2013 - Residency schedule, burnout and patient care among
first-year residents.
September 4, 2013
Block L, Wu AW, Feldman LS, et al. Residency schedule, burnout and patient care among first-year
residents. Postgrad Med J. 2013;89(1055):495-500. doi:10.1136/postgradmedj-2012-131743.
https://psnet.ahrq.gov/issue/residency-…
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psnet.ahrq.gov/node/45853/psn-pdf
April 24, 2018 - Rudeness and medical team performance.
April 24, 2018
Riskin A, Erez A, Foulk T, et al. Rudeness and Medical Team Performance. Pediatrics.
2017;139(2):e20162305. doi:10.1542/peds.2016-2305.
https://psnet.ahrq.gov/issue/rudeness-and-medical-team-performance
Disruptive and rude behavior by clinicians can hinder team…
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psnet.ahrq.gov/node/47997/psn-pdf
May 08, 2019 - Blind spots in the science of safety.
May 8, 2019
Bosk CL, Pedersen KZ. Blind spots in the science of safety. Lancet. 2019;393(10175):978-979.
doi:10.1016/S0140-6736(19)30441-6.
https://psnet.ahrq.gov/issue/blind-spots-science-safety
Safety sciences offer methods to enhance processes and develop organizational cul…
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psnet.ahrq.gov/node/37098/psn-pdf
October 04, 2011 - How residents think and make medical decisions:
implications for education and patient safety.
October 4, 2011
Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for
education and patient safety. Am Surg. 2007;73(6):548-553; discussion 553-4.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/839824/psn-pdf
November 09, 2022 - Improving diagnostic decision support through deliberate
reflection: a proposal.
November 9, 2022
Schmidt HG, Mamede S. Improving diagnostic decision support through deliberate reflection: a proposal.
Diagnosis (Berl). 2023;10(1):38-42. doi:10.1515/dx-2022-0062.
https://psnet.ahrq.gov/issue/improving-diagnostic-de…
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psnet.ahrq.gov/node/61073/psn-pdf
October 28, 2020 - Doctors' unconscious bias affects quality of health care
services, research shows.
October 28, 2020
Dembosky A. All Things Considered. National Public Radio. October 15, 2020.
https://psnet.ahrq.gov/issue/doctors-unconscious-bias-affects-quality-health-care-services-research-shows
Physician implicit bias is g…
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psnet.ahrq.gov/node/38416/psn-pdf
February 18, 2009 - Preanalytical errors in primary healthcare: a
questionnaire study of information search procedures,
test request management and test tube labelling.
February 18, 2009
Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study
of information search procedures, test …
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psnet.ahrq.gov/node/73546/psn-pdf
July 28, 2021 - A tragic death shows how ERs fail patients who struggle
with addiction.
July 28, 2021
Pattani A. Health Shots. National Public Radio. July 14, 2021.
https://psnet.ahrq.gov/issue/tragic-death-shows-how-ers-fail-patients-who-struggle-addiction
Patients with substance abuse disorders face challenges to safe…