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psnet.ahrq.gov/node/47317/psn-pdf
August 15, 2018 - Actions Needed to Address Employee Misconduct
Process and Ensure Accountability.
August 15, 2018
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
https://psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-
accountability
Both organi…
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psnet.ahrq.gov/node/852447/psn-pdf
August 16, 2023 - Patient safety in palliative care at the end of life from the
perspective of complex thinking.
August 16, 2023
Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Patient safety in palliative care at the end of life
from the perspective of complex thinking. Healthcare (Basel). 2023;11(14):2030.
doi:10.3390/hea…
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psnet.ahrq.gov/node/851197/psn-pdf
July 05, 2023 - Finnish emergency medical services managers' and
medical directors' perceptions of collaborating with
patients concerning patient safety issues: a qualitative
study.
July 5, 2023
Venesoja A, Tella S, Castrén M, et al. Finnish emergency medical services managers’ and medical
directors’ perceptions of collaborating…
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psnet.ahrq.gov/node/46182/psn-pdf
June 28, 2017 - What we know about designing an effective improvement
intervention (but too often fail to put into practice).
June 28, 2017
Marshall M, de Silva D, Cruickshank L, et al. What we know about designing an effective improvement
intervention (but too often fail to put into practice). BMJ Qual Saf. 2016;26(7). doi:10.113…
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psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - A target to achieve zero preventable trauma deaths
through quality improvement.
July 19, 2018
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through
Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
https://psnet.ahrq.gov/issue/target-achi…
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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings.
August 24, 2022
Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med
Care. 2022;60(10):775-783. doi:10.1097/mlr.0000000000001763.
https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ra…
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psnet.ahrq.gov/node/37903/psn-pdf
May 09, 2013 - Safe Surgery.
May 9, 2013
World Health Organization.
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge
This initiative provides a surgical safety checklist and related educational and training materials building on
the Second Global Patient Safety Challenge vision to enco…
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psnet.ahrq.gov/node/853622/psn-pdf
January 01, 2024 - Enhancing patient safety: a national standard for cyber
resiliency in healthcare.
September 20, 2023
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber
resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.1177/08404704231196138.
https://ps…
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psnet.ahrq.gov/node/40355/psn-pdf
July 09, 2012 - The Silent Treatment: Why Safety Tools and Checklists
Aren't Enough to Save Lives.
July 9, 2012
Maxfield D, Grenny J, Lavandero R, et al. Provo, UT: VitalSmarts; 2011.
https://psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
Silence Kills was a 2005 report that highligh…
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psnet.ahrq.gov/node/866163/psn-pdf
June 19, 2024 - Performance evaluation of ChatGPT in detecting
diagnostic errors and their contributing factors: an
analysis of 545 case reports of diagnostic errors.
June 19, 2024
Harada Y, Suzuki T, Harada T, et al. Performance evaluation of ChatGPT in detecting diagnostic errors
and their contributing factors: an analysis of 5…
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psnet.ahrq.gov/node/44334/psn-pdf
November 20, 2015 - Improvement in detection of wrong-patient errors when
radiologists include patient photographs in their
interpretation of portable chest radiographs.
November 20, 2015
Tridandapani S, Olsen K, Bhatti P. Improvement in Detection of Wrong-Patient Errors When Radiologists
Include Patient Photographs in Their Interpre…
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psnet.ahrq.gov/node/73311/psn-pdf
January 01, 2022 - Key considerations in ensuring a safe regional telehealth
care model: a systematic review.
May 26, 2021
Haveland S, Islam S. Key considerations in ensuring a safe regional telehealth care model: a systematic
review. Telemed J E Health. 2022;28(5):602-612. doi:10.1089/tmj.2020.0580.
https://psnet.ahrq.gov/issue/key…
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psnet.ahrq.gov/node/846447/psn-pdf
March 22, 2023 - Prosocial voice in the hierarchy of healthcare
professionals: the role of emotions after harmful patient
safety incidents.
March 22, 2023
Richmond JG, Burgess N. Prosocial voice in the hierarchy of healthcare professionals: the role of emotions
after harmful patient safety incidents. J Health Organ Manag. 2023;37(…
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psnet.ahrq.gov/node/47725/psn-pdf
March 06, 2019 - Overcoming human barriers to safety event reporting in
radiology.
March 6, 2019
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in
Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
https://psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-…
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psnet.ahrq.gov/node/837697/psn-pdf
July 20, 2022 - Outsourcing health-care services to the private sector
and treatable mortality rates in England, 2013-20: an
observational study of NHS privatisation.
July 20, 2022
Goodair B, Reeves A. Outsourcing health-care services to the private sector and treatable mortality rates in
England, 2013–20: an observational study …
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psnet.ahrq.gov/node/44005/psn-pdf
April 08, 2015 - Case report of a medication error by look-alike packaging:
a classic surrogate marker of an unsafe system.
April 8, 2015
Schnoor J, Rogalski C, Frontini R, et al. Case report of a medication error by look-alike packaging: a
classic surrogate marker of an unsafe system. Patient Saf Surg. 2015;9:12. doi:10.1186/s1303…
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psnet.ahrq.gov/node/35448/psn-pdf
September 18, 2009 - Relationship between performance measurement and
accreditation: implications for quality of care and patient
safety.
September 18, 2009
Miller MR, Pronovost P, Donithan M, et al. Relationship between performance measurement and
accreditation: implications for quality of care and patient safety. Am J Med Qual. 2005…
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psnet.ahrq.gov/node/41045/psn-pdf
July 02, 2014 - Relating faults in diagnostic reasoning with diagnostic
errors and patient harm.
July 2, 2014
Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient
harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6.
https://psnet.ahrq.gov/issue/relating-fau…
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psnet.ahrq.gov/node/43141/psn-pdf
April 30, 2014 - Engaging residents and fellows to improve institution-
wide quality: the first six years of a novel financial
incentive program.
April 30, 2014
Vidyarthi A, Green AL, Rosenbluth G, et al. Engaging residents and fellows to improve institution-wide
quality: the first six years of a novel financial incentive program.…
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psnet.ahrq.gov/node/47323/psn-pdf
September 26, 2018 - About politeness, face, and feedback: exploring resident
and faculty perceptions of how institutional feedback
culture influences feedback practices.
September 26, 2018
Ramani S, Könings KD, Mann K, et al. About Politeness, Face, and Feedback: Exploring Resident and
Faculty Perceptions of How Institutional Feedbac…