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psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume-referral-center
January 11, 2017 - Study
Classic
Safety of overlapping surgery at a high-volume referral center.
Citation Text:
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center. Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084. …
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psnet.ahrq.gov/issue/chief-residents-quality-improvement-and-patient-safety-recipe-new-role-graduate-medical
August 13, 2014 - Commentary
Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education.
Citation Text:
Ferraro K, Zernzach R, Maturo S, et al. Chief of Residents for Quality Improvement and Patient Safety: A Recipe for a New Role in Graduate Medic…
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psnet.ahrq.gov/issue/can-we-rely-patients-reports-adverse-events
December 29, 2014 - Study
Classic
Can we rely on patients' reports of adverse events?
Citation Text:
Zhu J, Stuver SO, Epstein AM, et al. Can we rely on patients' reports of adverse events? Med Care. 2011;49(10):948-55. doi:10.1097/MLR.0b013e31822047a8.
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psnet.ahrq.gov/issue/increasing-rate-detection-wrong-patient-radiographs-use-photographs-obtained-time-radiography
June 13, 2015 - Study
Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography.
Citation Text:
Tridandapani S, Ramamurthy S, Galgano SJ, et al. Increasing Rate of Detection of Wrong-Patient Radiographs: Use of Photographs Obtained at Time of Radiograp…
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psnet.ahrq.gov/issue/how-willing-are-patients-question-healthcare-staff-issues-related-quality-and-safety-their
July 31, 2008 - Study
How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.
Citation Text:
Davis R, Koutantji M, Vincent C. How willing are patients to question healthcare staff on issues related to the quality and …
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psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
March 16, 2016 - Study
Root cause analyses of suicides of mental health clients.
Citation Text:
Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies. Crisis. 2015;36(5):316-324. doi:10.1027/02…
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psnet.ahrq.gov/issue/vignette-study-examine-health-care-professionals-attitudes-towards-patient-involvement-error
March 11, 2013 - Study
A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention.
Citation Text:
Schwappach DLB, Frank O, Davis R. A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention. J…
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psnet.ahrq.gov/node/42373/psn-pdf
June 19, 2013 - Hospitals lagging in PSO contracts.
June 19, 2013
Clarke C. HealthLeaders Media. June 6, 2013.
https://psnet.ahrq.gov/issue/hospitals-lagging-pso-contracts
This news piece examines why few hospitals participate in the AHRQ Patient Safety Organizations
program.
https://psnet.ahrq.gov/issue/hospitals-lagging-pso-co…
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psnet.ahrq.gov/node/41236/psn-pdf
March 29, 2018 - Speak Up video posters.
March 29, 2018
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/speak-video-posters
The Speak Up video series encourages patients to actively participate in their care. Posters to complement
the video series, in both English and Spanish are available upon request.
http…
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psnet.ahrq.gov/node/40314/psn-pdf
January 31, 2018 - Speak Up Video Series.
January 31, 2018
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/speak-video-series
This video series illustrates techniques for patients to actively participate in their care. Episodes are
available in both English and Spanish and are accompanied by transcripts. …
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psnet.ahrq.gov/node/33994/psn-pdf
March 17, 2011 - San Diego Center for Patient Safety.
March 17, 2011
https://psnet.ahrq.gov/issue/san-diego-center-patient-safety
The San Diego Center for Patient Safety (SDCPS) consists of a multidisciplinary team and an associated
research infrastructure. The SDCPS provides for patient safety education and supports the introducti…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/40077/psn-pdf
July 10, 2012 - Improvement Cymru.
July 10, 2012
NHS Wales.
https://psnet.ahrq.gov/issue/improvement-cymru
This national program draws from other large collaborative efforts to engage health care organizations
across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43314/psn-pdf
August 15, 2018 - ISQua Fellowship Programme.
August 15, 2018
International Society for Quality in Health Care.
https://psnet.ahrq.gov/issue/isqua-fellowship-programme
This announcement highlights a peer learning initiative that builds on existing programs and
interdisciplinary networks to develop participants' understanding about …
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psnet.ahrq.gov/node/34855/psn-pdf
March 07, 2005 - Pharmacists play key role in patient safety.
March 7, 2005
https://psnet.ahrq.gov/issue/pharmacists-play-key-role-patient-safety
Description of a successful model from Duke University (SD), where hospital pharmacists play an integral
role in patient care. They provide counseling for patients, support for medical te…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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psnet.ahrq.gov/node/39466/psn-pdf
June 27, 2018 - Patient engagement in patient safety: barriers and
facilitators.
June 27, 2018
Scobie AC, Persaud DD. Patient Saf Qual Healthc. March/April 2010;7:42-47.
https://psnet.ahrq.gov/issue/patient-engagement-patient-safety-barriers-and-facilitators
This article reviews the literature and describes a framework for patien…
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psnet.ahrq.gov/node/41874/psn-pdf
November 21, 2012 - Reducing Diagnostic Errors.
November 21, 2012
Boston, MA: National Patient Safety Foundation; 2011.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors
This online continuing education module will educate participants on diagnostic errors, including
contributing factors and prevention strategies. Dr. Mark Grab…
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psnet.ahrq.gov/issue/development-testing-and-findings-pediatric-focused-trigger-tool-identify-medication-related
April 11, 2011 - Study
Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.
Citation Text:
Takata GS, Mason W, Taketomo C, et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medicati…
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psnet.ahrq.gov/issue/system-hazards-managing-laboratory-test-requests-and-results-primary-care-medical-protection
November 08, 2017 - Study
System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model.
Citation Text:
Bowie P, Price J, Hepworth N, et al. System hazards in managing laboratory test requests and results in primary care: medical p…