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psnet.ahrq.gov/node/853968/psn-pdf
January 01, 2024 - When work harms: how better understanding of avoidable
employee harm can improve employee safety, patient
safety and healthcare quality.
September 27, 2023
Jones A, Neal A, Bailey S, et al. When work harms: how better understanding of avoidable employee harm
can improve employee safety, patient safety and healthca…
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psnet.ahrq.gov/node/39533/psn-pdf
May 25, 2015 - The relationship between patient safety culture and the
implementation of organizational patient safety defences
at emergency departments.
May 25, 2015
van Noord I, de Bruijne M, Twisk JWR. The relationship between patient safety culture and the
implementation of organizational patient safety defences at emergency…
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psnet.ahrq.gov/node/867038/psn-pdf
October 30, 2024 - From reporting to improving: how root cause analysis in
teams shape patient safety culture.
October 30, 2024
Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams
shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-1858. doi:10.2147/rmhp.s466852.
h…
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psnet.ahrq.gov/node/866517/psn-pdf
August 14, 2024 - Feedback loop failure modes in medical diagnosis: how
biases can emerge and be reinforced.
August 14, 2024
Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can
emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612.
https://p…
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psnet.ahrq.gov/node/865806/psn-pdf
May 08, 2024 - Entangled in complexity: an ethnographic study of
organizational adaptability and safe care transitions for
patients with complex care needs.
May 8, 2024
Hedqvist A?T, Praetorius G, Ekstedt M, et al. Entangled in complexity: an ethnographic study of
organizational adaptability and safe care transitions for patient…
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psnet.ahrq.gov/node/61064/psn-pdf
October 28, 2020 - Feasibility of patient-reported diagnostic errors following
emergency department discharge: a pilot study.
October 28, 2020
Gleason KT, Peterson SM, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors
following emergency department discharge: a pilot study. Diagnosis (Berl). 2021;8(2):1…
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psnet.ahrq.gov/node/61044/psn-pdf
January 01, 2021 - Seven features of safety in maternity units: a framework
based on multisite ethnography and stakeholder
consultation.
October 21, 2020
Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in maternity units: a framework based on
multisite ethnography and stakeholder consultation. BMJ Qual Saf. 2021;3…
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psnet.ahrq.gov/node/60646/psn-pdf
July 01, 2020 - An integrative total worker health framework for keeping
workers safe and healthy during the COVID-19 pandemic.
July 1, 2020
Dennerlein JT, Burke L, Sabbath EL, et al. An Integrative Total Worker Health Framework for Keeping
Workers Safe and Healthy During the COVID-19 Pandemic. Hum Factors. 2020;62(5):689–696.
do…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show?
David A. Cook, MD, MHPE | March 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Cook DA. The Literature on Health Care Simulation Education: What Do…
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common?
Mark L. Graber, MD | February 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioid …
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTe…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
Citation Text:
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up
June 14, 2023
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
The Case
A 63-year-old man with history of stroke, systolic heart failure, and ventric…
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…