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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Furthermore, decreased bed availability, ED overcrowding, and hospitals operating at full capacity often
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Communication failures in the operating room: an observational
classification of recurrent types and
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - Essentially functioning as a "red rule," similar to how operating room nurses ensure that all are properly
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-hospitals
February 22, 2017 - Book/Report
Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals.
Citation Text:
Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals. Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
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psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
January 29, 2018 - Newspaper/Magazine Article
Drug name confusion: preventing medication errors.
Citation Text:
Rados C. Drug name confusion: preventing medication errors. FDA consumer. 2005;39(4):35-7.
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psnet.ahrq.gov/issue/pediatric-safety
March 08, 2015 - Newspaper/Magazine Article
Pediatric safety.
Citation Text:
Runy LA. Pediatric safety. Hospitals & health networks. 2009;83(5):8 p following 32, 2.
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psnet.ahrq.gov/issue/guide-developing-community-based-patient-safety-advisory-council
November 30, 2016 - Toolkit
Guide for Developing a Community-Based Patient Safety Advisory Council.
Citation Text:
Guide for Developing a Community-Based Patient Safety Advisory Council. Leonhardt, K, Bonin D, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication N…
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psnet.ahrq.gov/issue/global-medical-supply-chain-security
September 20, 2017 - Special or Theme Issue
Global Medical Supply Chain Security.
Citation Text:
Global Medical Supply Chain Security. Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.
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psnet.ahrq.gov/issue/medication-errors-affecting-pediatric-patients-unique-challenges-special-population
January 20, 2016 - Newspaper/Magazine Article
Medication errors affecting pediatric patients: unique challenges for this special population.
Citation Text:
Medication errors affecting pediatric patients: unique challenges for this special population. Grissinger M. PA-PSRS Patient Saf Advis. September 2015;…
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psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
May 03, 2023 - Book/Report
Serious Reportable Events in Massachusetts.
Citation Text:
Serious Reportable Events in Massachusetts. Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
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psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
February 11, 2015 - Book/Report
Medicare's Oversight of Ambulatory Surgery Centers Report.
Citation Text:
Medicare's Oversight of Ambulatory Surgery Centers Report. Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
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psnet.ahrq.gov/issue/risk-management-obstetrics-and-gynaecology
June 15, 2011 - Special or Theme Issue
Risk Management in Obstetrics and Gynaecology.
Citation Text:
Risk Management in Obstetrics and Gynaecology. Edozien LC, ed. Best Pract Res Clin Obstet Gynaecol. 2013;27:A1-A14,479-640.
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psnet.ahrq.gov/issue/how-veterans-affairs-failed-stop-pathologist-who-misdiagnosed-3000-cases
October 23, 2019 - Newspaper/Magazine Article
How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases.
Citation Text:
How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases. Rein L. Washington Post. August 30, 2019.
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psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success
August 20, 2018 - Book/Report
Leading a Culture of Safety: a Blueprint for Success.
Citation Text:
Leading a Culture of Safety: a Blueprint for Success. Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017.
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psnet.ahrq.gov/issue/positive-patient-identification
June 19, 2024 - Book/Report
Positive Patient Identification.
Citation Text:
Positive Patient Identification. Healthcare Safety Investigation Branch (HSIB), Dorset, UK: Health Services Safety Investigations Body; February 2024.
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psnet.ahrq.gov/issue/some-doctors-questioning-whether-shorter-shifts-interns-are-endangering-patients
July 26, 2017 - Newspaper/Magazine Article
Some doctors questioning whether shorter shifts for interns are endangering patients.
Citation Text:
Some doctors questioning whether shorter shifts for interns are endangering patients. Boodman SG. Kaiser Health News. July 9, 2013.
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psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare
June 30, 2019 - Commentary
Measuring shared mental models in healthcare.
Citation Text:
Measuring shared mental models in healthcare. Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219.
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