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psnet.ahrq.gov/node/36773/psn-pdf
August 21, 2007 - Better: A Surgeon's Notes on Performance.
August 21, 2007
Gawande A. New York, NY: Metropolitan; 2007.
https://psnet.ahrq.gov/issue/better-surgeons-notes-performance
This book includes essays on the social and professional conventions that can affect a physician's ability to
provide safe and effective care. Gawand…
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psnet.ahrq.gov/node/38946/psn-pdf
July 03, 2013 - 2009 Older Adults' Knowledge About Medications That
Can Impact Driving.
July 3, 2013
MacLennan PA, Owsley C, Rue LW III, McGwin G Jr. Washington, DC: American Automobile Association
Foundation for Traffic Safety; August 2009.
https://psnet.ahrq.gov/issue/2009-older-adults-knowledge-about-medications-c…
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psnet.ahrq.gov/node/35018/psn-pdf
November 28, 2018 - Your company's secret change agents.
November 28, 2018
Pascale RT, Sternin J. Your company's secret change agents. Harv Bus Rev. 2005;83(5):72-81, 153.
https://psnet.ahrq.gov/issue/your-companys-secret-change-agents
The authors describe how to leverage "positive deviants," individuals within an organization who fin…
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psnet.ahrq.gov/node/37463/psn-pdf
January 06, 2017 - Implementing an MET-based RRS at Toronto General
Hospital.
January 6, 2017
Warner MB, Reynolds SF. Implementing an MET-based RRS at Toronto General Hospital. Jt Comm J Qual
Patient Saf. 2008;34(1):57-9, 1.
https://psnet.ahrq.gov/issue/implementing-met-based-rrs-toronto-general-hospital
This article describes one …
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psnet.ahrq.gov/node/73548/psn-pdf
July 27, 2021 - Diagnostic Errors in Primary Care.
July 27, 2021
Betsy Lehman Center for Patient Safety.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care
Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This
website supports learning generated from the Primary-Care…
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psnet.ahrq.gov/node/43032/psn-pdf
June 17, 2014 - EAU policy on live surgery events.
June 17, 2014
Artibani W, Ficarra V, Challacombe BJ, et al. EAU policy on live surgery events. Eur Urol. 2014;66(1):87-
97. doi:10.1016/j.eururo.2014.01.028.
https://psnet.ahrq.gov/issue/eau-policy-live-surgery-events
The practice of live surgical procedures for educational purpo…
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psnet.ahrq.gov/node/37980/psn-pdf
October 28, 2009 - Double checking medicines: defence against error or
contributory factor?
October 28, 2009
Armitage G. Double checking medicines: defence against error or contributory factor? J Eval Clin Pract.
2008;14(4):513-9.
https://psnet.ahrq.gov/issue/double-checking-medicines-defence-against-error-or-contributory-factor
Th…
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psnet.ahrq.gov/node/38497/psn-pdf
July 13, 2009 - Social aspects of clinical errors: a discussion paper.
July 13, 2009
Richman J, Mason T, Mason-Whitehead E, et al. Social aspects of clinical errors. Int J Nurs Stud.
2009;46(8). doi:10.1016/j.ijnurstu.2009.01.006.
https://psnet.ahrq.gov/issue/social-aspects-clinical-errors-discussion-paper
This article engages wi…
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psnet.ahrq.gov/node/35124/psn-pdf
June 29, 2005 - JCAHO proposal for patient-centered care brings concept
to mainstream healthcare settings.
June 29, 2005
ECRI. Risk Management Reporter. June 2005.
https://psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare-
settings
This commentary provides a definition of patient-cent…
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psnet.ahrq.gov/node/36416/psn-pdf
December 22, 2010 - A medical error leads to tragedy: how do we inform the
patient?
December 22, 2010
Baumrucker SJ. A medical error leads to tragedy: how do we inform the patient? Am J Hosp Palliat Care.
2006;23(5):417-21.
https://psnet.ahrq.gov/issue/medical-error-leads-tragedy-how-do-we-inform-patient
This roundtable discussion p…
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psnet.ahrq.gov/node/41716/psn-pdf
September 26, 2012 - International advocacy for education and safety.
September 26, 2012
McQueen KA, Malviya S, Gathuya ZN, et al. International advocacy for education and safety. Paediatr
Anaesth. 2012;22(10):962-8. doi:10.1111/pan.12008.
https://psnet.ahrq.gov/issue/international-advocacy-education-and-safety
Describing challenges t…
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psnet.ahrq.gov/node/38450/psn-pdf
March 04, 2009 - Variability in pharmacy interpretations of physician
prescriptions.
March 4, 2009
Wolf MS, Shekelle PG, Choudhry NK, et al. Variability in pharmacy interpretations of physician
prescriptions. Med Care. 2009;47(3):370-373. doi:10.1097/MLR.0b013e31818af91a.
https://psnet.ahrq.gov/issue/variability-pharmacy-interpret…
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psnet.ahrq.gov/node/39272/psn-pdf
February 03, 2010 - Patient safety and diagnostic error: tips for your next
shift.
February 3, 2010
Sinclair D, Croskerry P. Patient safety and diagnostic error: tips for your next shift. Can Fam Physician.
2010;56(1):28-30.
https://psnet.ahrq.gov/issue/patient-safety-and-diagnostic-error-tips-your-next-shift
Through case examples, …
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psnet.ahrq.gov/node/50900/psn-pdf
February 12, 2020 - How to "DEAL" with disruptive physician behavior.
February 12, 2020
Junga Z, Tritsch A, Singla M. How to “DEAL” With disruptive physician behavior. Gastroenterology.
2019;157(6):1469-1472. doi:10.1053/j.gastro.2019.10.021.
https://psnet.ahrq.gov/issue/how-deal-disruptive-physician-behavior
In this commentary, the …
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psnet.ahrq.gov/node/34632/psn-pdf
March 28, 2005 - Keeping Each Patient Safe.
March 28, 2005
University of Pittsburgh Schools of the Health Sciences
https://psnet.ahrq.gov/issue/keeping-each-patient-safe
A collection of three educational modules that address key areas of concern in patient safety. These
include protecting patients from hospital-acquired infection,…
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - Guidelines for Design and Construction.
February 5, 2019
St Louis, Missouri; Facilities Guidelines Institute; 2018.
https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design changes, such as the adoption of private rooms to reduce
medical error, interruptions, and hosp…
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psnet.ahrq.gov/node/43642/psn-pdf
November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report
Prepared for the Department of Health.
November 5, 2014
London, UK: Frontier Economics Ltd; October 2014.
https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health
This report provides an overview of evidence on preventabl…
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psnet.ahrq.gov/node/43055/psn-pdf
May 01, 2017 - AHRQ's Safety Program for Ambulatory Surgery.
May 1, 2017
Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May
2017. AHRQ Publication No. 16(17)-0019-1-EF.
https://psnet.ahrq.gov/issue/ahrqs-safety-program-ambulatory-surgery
This report provides information about a na…
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psnet.ahrq.gov/node/39825/psn-pdf
June 10, 2018 - Electronic prescribing vulnerabilities: height and weight
mix-up leads to dosing error.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1-3.
https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
This article discusses a case …
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psnet.ahrq.gov/node/35455/psn-pdf
July 13, 2010 - Urban outpatient views on quality and safety in primary
care.
July 13, 2010
Dowell D, Manwell LB, Maguire A, et al. Urban outpatient views on quality and safety in primary care.
Healthc Q. 2005;8(2):suppl 2-8.
https://psnet.ahrq.gov/issue/urban-outpatient-views-quality-and-safety-primary-care
In this AHRQ-funded …