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psnet.ahrq.gov/issue/how-event-reporting-us-hospitals-has-changed-2005-2009
April 21, 2010 - Study
How event reporting by US hospitals has changed from 2005 to 2009.
Citation Text:
Farley DO, Haviland AM, Haas A, et al. How event reporting by US hospitals has changed from 2005 to 2009. BMJ Qual Saf. 2011;21(1). doi:10.1136/bmjqs-2011-000114.
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psnet.ahrq.gov/issue/examination-opportunities-active-patient-improving-patient-safety
October 04, 2011 - Review
An examination of opportunities for the active patient in improving patient safety.
Citation Text:
Davis R, Sevdalis N, Jacklin R, et al. An examination of opportunities for the active patient in improving patient safety. J Patient Saf. 2012;8(1):36-43. doi:10.1097/PTS.0b013e318…
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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/issue/sepsis-early-recognition-and-response-initiative-serri
November 11, 2015 - Commentary
The Sepsis Early Recognition and Response Initiative (SERRI).
Citation Text:
Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt Comm J Qual Patient Saf. 2016;42(3):122-138.
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psnet.ahrq.gov/node/35548/psn-pdf
January 01, 2006 - Patient Safety 2006.
December 7, 2005
National Patient Safety Agency.
https://psnet.ahrq.gov/issue/patient-safety-2006
This conference gave participants the opportunity to select one of seven educational tracks on
understanding and implementing improvements in patient safety. A selection of the presentations
and …
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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/40076/psn-pdf
October 20, 2014 - Learning to Use Patient Stories.
October 20, 2014
Cardiff, UK: NHS Wales; April 2010.
https://psnet.ahrq.gov/issue/learning-use-patient-stories
This report provides insights from participants in the 1000 Lives Campaign on how patient stories can focus
attention on safety improvements and drive commitment to change…
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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/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…
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psnet.ahrq.gov/issue/disparity-frontline-clinical-staff-and-managers-perceptions-quality-and-patient-safety
February 01, 2011 - Study
The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.
Citation Text:
Parand A, Burnett S, Benn J, et al. The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative. J Eva…