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psnet.ahrq.gov/node/38007/psn-pdf
September 05, 2008 - Building a Culture of Patient Safety: Report of the
Commission on Patient Safety and Quality Assurance.
September 5, 2008
Dublin, Ireland: Department of Health & Children, Commission on Patient Safety and Quality
Assurance; 2008. ISBN: 9781406421835.
https://psnet.ahrq.gov/issue/building-culture-patient-safety-rep…
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psnet.ahrq.gov/node/40728/psn-pdf
October 21, 2011 - What prevents incident disclosure, and what can be done
to promote it?
October 21, 2011
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote
it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…
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psnet.ahrq.gov/node/46617/psn-pdf
February 21, 2018 - Supporting second victims.
February 21, 2018
Quick Safety. January 22, 2018;(39):1-3.
https://psnet.ahrq.gov/issue/supporting-second-victims
Involvement in patient harm can result in serious psychological consequences for health care workers. This
newsletter article describes problems second victims may experience…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/node/867698/psn-pdf
October 01, 2024 - Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 1, 2024
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 2024.
https://psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
Methicillin-resistant Staphylococcus aureus (MRSA) infect…
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psnet.ahrq.gov/node/36110/psn-pdf
April 04, 2024 - Sentinel Event Data Summary.
April 4, 2024
Joint Commission.
https://psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019
This website provides sentinel event data reported to The Joint Commission, which includes information on
sentinel events reported from January through December 2023. Falls, wrong surgery a…
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psnet.ahrq.gov/node/50595/psn-pdf
January 01, 2020 - Clinical reasoning as a core competency.
October 30, 2019
Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med.
2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027.
https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency
Enhancing clinical reasoning skill, particularly amon…
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psnet.ahrq.gov/node/33922/psn-pdf
August 05, 2009 - The importance of cognitive errors in diagnosis and
strategies to minimize them.
August 5, 2009
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med.
2003;78(8):775-780.
https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them…
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psnet.ahrq.gov/node/836868/psn-pdf
April 06, 2022 - HEAR Her Concerns.
April 6, 2022
National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health;
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/hear-her-concerns
Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…
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psnet.ahrq.gov/node/35015/psn-pdf
June 16, 2011 - Keeping Patients Safe: Transforming the Work
Environment of Nurses.
June 16, 2011
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…
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psnet.ahrq.gov/node/852458/psn-pdf
June 01, 2019 - The patient's role in patient safety.
June 1, 2019
Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am.
2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004.
https://psnet.ahrq.gov/issue/patients-role-patient-safety
Patients and their families can play an important role i…
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psnet.ahrq.gov/node/35523/psn-pdf
December 14, 2010 - ISMP Medication Errors Reporting Program.
December 14, 2010
Institute for Safe Medication Practices
https://psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program
The Institute for Safe Medication Practices (ISMP) administers this national reporting program, which
collects confidential reports of medication…
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psnet.ahrq.gov/node/35327/psn-pdf
March 15, 2017 - Common Program Requirements. The Learning and
Working Environment (Duty Hours).
March 15, 2017
Accreditation Council for Graduate Medical Education.
https://psnet.ahrq.gov/issue/common-program-requirements-learning-and-working-environment-duty-hours
This website provides information about efforts to study and set …
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psnet.ahrq.gov/node/44873/psn-pdf
March 21, 2016 - Malpractice Risks in Communication Failures: 2015
Annual Benchmarking Report.
March 21, 2016
Cambridge, MA: CRICO Strategies; 2016.
https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
Communication failures are known to contribute to medical errors. Analyzing more …
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psnet.ahrq.gov/node/47999/psn-pdf
May 15, 2019 - Pregnancy-related deaths: saving women’s lives before,
during and after delivery.
May 15, 2019
CDC Vital Signs. May 7, 2019.
https://psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis desc…
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psnet.ahrq.gov/node/38022/psn-pdf
August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road
rage affecting patient safety, group says.
August 27, 2008
Kowalczyk L.
https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient-
safety-group-says
This article describes how physician outbursts can affect patient …