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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - Joint Commission on Accreditation of Healthcare Organizations Web site. Accessed May 7, 2004.
6.
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - provide
patient- and family-centered care.(11,12) Clinical outcomes are improved when health care organizations
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - Joint Commission on Accreditation of Healthcare Organizations Web
site. Accessed May 7, 2004.
6.
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - women experience pregnancy-related deaths at nearly four times the rate of white women.( 2 ) Several organizations
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - health care providers and the general public.( 15 ) The Joint Commission on Accreditation of Healthcare Organizations
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - Bluebonnet Trails is a large safety net mental healthcare organization, and in the past year I've had … In DC, Urgent Wellness works with a large Medicaid managed care organization, AmeriHealth, and we contracted … I do think that in ACO [accountable care organization] and pay-for-quality models of care, there's a … Interview
In Conversation with Timothy Vogus about High Reliability Organization … February 26, 2025
Perspective
High Reliability Organization
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psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - These universal checklists are recommended by the World Health Organization and required by the Joint … Geneva: World Health Organization; 2009. [ Available at ]
Gfrerer L, Mattos D, Mastroianni M, et al
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - But the hospital is also a very complex functional organization. … RW: How would you try to apply this thinking in a health care organization?
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psnet.ahrq.gov/issue/its-probably-sti-because-youre-gay-qualitative-study-diagnostic-error-experiences-sexual-and
November 02, 2022 - Study
"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.
Citation Text:
Wiegand AA, Sheikh T, Zannath F, et al. “It’s probably an STI because you’re gay”: a qualitative study of diagnostic error experi…
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psnet.ahrq.gov/issue/surgical-safety-checklist-audits-may-be-misleading-improving-implementation-and-adherence
November 24, 2021 - Study
Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.
Citation Text:
Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving th…
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psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
September 25, 2008 - Study
Where are my instruments? Hazards in delivery of surgical instruments.
Citation Text:
Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7.
Copy Citat…
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psnet.ahrq.gov/issue/my-five-moments-hand-hygiene-user-centred-design-approach-understand-train-monitor-and-report
September 09, 2020 - Commentary
'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.
Citation Text:
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and …
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psnet.ahrq.gov/issue/diagnostic-discrepancies-between-antemortem-clinical-diagnosis-and-autopsy-findings-pediatric
July 28, 2021 - Study
Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.
Citation Text:
Raghuram N, Alodan K, Bartels U, et al. Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.…
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psnet.ahrq.gov/issue/improving-patient-safety-identifying-side-effects-introducing-bar-coding-medication
March 11, 2011 - Study
Classic
Improving patient safety by identifying side effects from introducing bar coding in medication administration.
Citation Text:
Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in me…
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psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
September 15, 2021 - Commentary
Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.
Citation Text:
Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of t…
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psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
September 02, 2016 - Congressional Testimony
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
Citation Text:
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. Hearing Before the Subcommittee on Primary Health and Aging, 113th Co…
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psnet.ahrq.gov/issue/piloting-patient-safety-and-quality-improvement-co-curriculum
March 22, 2023 - Commentary
Piloting a patient safety and quality improvement co-curriculum.
Citation Text:
Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co-curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357. doi:10.1080/20009666.2017.14038…
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psnet.ahrq.gov/issue/anesthesia-preinduction-checklist-improve-information-exchange-knowledge-critical-information
July 10, 2013 - Study
An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams.
Citation Text:
Tscholl DW, Weiss M, Kolbe M, et al. An Anesthesia Preinduction Checklist to Improv…
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psnet.ahrq.gov/issue/i-am-administering-medication-please-do-not-interrupt-me-red-tabards-preventing-interruptions
May 12, 2021 - Study
"I am administering medication—please do not interrupt me": red tabards preventing interruptions as perceived by surgical patients.
Citation Text:
Palese A, Ferro M, Pascolo M, et al. "I Am Administering Medication-Please Do Not Interrupt Me": Red Tabards Preventing Interruptions a…
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psnet.ahrq.gov/issue/adverse-events-are-common-intensive-care-unit-results-structured-record-review
January 28, 2010 - Study
Adverse events are common on the intensive care unit: results from a structured record review.
Citation Text:
Nilsson L, Pihl A, Tågsjö M, et al. Adverse events are common on the intensive care unit: results from a structured record review. Acta Anaesthesiol Scand. 2012;56(8):959…