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psnet.ahrq.gov/node/42686/psn-pdf
April 16, 2019 - Improving the quality of health care: what's taking so
long?
April 16, 2019
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff.
2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
https://psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
Almost a decade-and…
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psnet.ahrq.gov/node/41464/psn-pdf
November 26, 2014 - Risk of unintentional overdose with non-prescription
acetaminophen products.
November 26, 2014
Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen
products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3.
https://psnet.ahrq.gov/issue/risk-uni…
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psnet.ahrq.gov/node/45862/psn-pdf
February 08, 2017 - Learning, Candour and Accountability. A Review of the
Way NHS Trusts Review and Investigate the Deaths of
Patients in England.
February 8, 2017
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
https://psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-rev…
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psnet.ahrq.gov/node/836823/psn-pdf
March 30, 2022 - Five-year audit of adherence to an anaesthesia pre-
induction checklist.
March 30, 2022
Fuchs A, Frick S, Huber M, et al. Five?year audit of adherence to an anaesthesia pre?induction checklist.
Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704.
https://psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthes…
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psnet.ahrq.gov/node/43581/psn-pdf
December 26, 2014 - Moving beyond misuse and diversion: the urgent need to
consider the role of iatrogenic addiction in the current
opioid epidemic.
December 26, 2014
Beauchamp GA, Winstanley EL, Ryan SA, et al. Moving beyond misuse and diversion: the urgent need to
consider the role of iatrogenic addiction in the current opioid epid…
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psnet.ahrq.gov/node/45784/psn-pdf
April 03, 2017 - Processes for identifying and reviewing adverse events
and near misses at an academic medical center.
April 3, 2017
Martinez W, Lehmann LS, Hu Y-Y, et al. Processes for Identifying and Reviewing Adverse Events and
Near Misses at an Academic Medical Center. Jt Comm J Qual Patient Saf. 2017;43(1):5-15.
doi:10.1016/j…
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psnet.ahrq.gov/node/851663/psn-pdf
July 26, 2023 - Quality of Care Concerns and the Facility Response
Following a Medical Emergency at the VA Southern
Nevada Health Care System in Las Vegas.
July 26, 2023
Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.
https://psnet.ahrq.gov/issue/quality-care-concerns-and-facility-…
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psnet.ahrq.gov/issue/affordable-health-care-floridians-act
January 15, 2025 - Legislation/Regulation
Affordable Health Care for Floridians Act.
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August 27, 2008
Established the patient safety center in the st…
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psnet.ahrq.gov/node/44688/psn-pdf
February 23, 2018 - Improving diagnosis in health care—the next imperative
for patient safety.
February 23, 2018
Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New
Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp1512241.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care…
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psnet.ahrq.gov/node/837677/psn-pdf
July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient
Diagnosed with Prostate Cancer at the Hampton VA
Medical Center in Virginia.
July 13, 2022
Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.
https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-…
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psnet.ahrq.gov/node/46092/psn-pdf
July 11, 2017 - Development of a research agenda to identify evidence-
based strategies to improve physician wellness and
reduce burnout.
July 11, 2017
Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based
Strategies to Improve Physician Wellness and Reduce Burnout. Ann Intern Med. 2017…
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psnet.ahrq.gov/node/47251/psn-pdf
July 25, 2018 - Fail-safe patient ID matching remains just out of reach.
July 25, 2018
Arndt RZ. Mod Healthc. July 14, 2018.
https://psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital
technologies can …
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psnet.ahrq.gov/node/47399/psn-pdf
November 14, 2018 - Leveraging the continuum: a novel approach to meeting
quality improvement and patient safety competency
requirements across a large department of medicine.
November 14, 2018
Myers JS, Bellini LM. Leveraging the Continuum: A Novel Approach to Meeting Quality Improvement and
Patient Safety Competency Requirements Ac…
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psnet.ahrq.gov/node/39893/psn-pdf
November 02, 2010 - Surgical safety and hospital volume across a wide range
of interventions.
November 2, 2010
Eggli Y, Halfon P, Meylan D, et al. Surgical safety and hospital volume across a wide range of
interventions. Med Care. 2010;48(11):962-71. doi:10.1097/MLR.0b013e3181eaf9f6.
https://psnet.ahrq.gov/issue/surgical-safety-and-h…
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psnet.ahrq.gov/node/50732/psn-pdf
December 11, 2019 - Association between physician depressive symptoms and
medical errors: A systematic review and meta-analysis
December 11, 2019
Pereira-Lima K, Mata DA, Loureiro SR, et al. Association Between Physician Depressive Symptoms and
Medical Errors: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(11):e1916097.…
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psnet.ahrq.gov/node/837428/psn-pdf
June 15, 2022 - A retrospective review of serious surgical incidents in 5
large UK teaching hospitals: a system-based approach.
June 15, 2022
Serou N, Slight RD, Husband AK, et al. A retrospective review of serious surgical incidents in 5 large UK
teaching hospitals: a system-based approach. J Patient Saf. 2022;18(4):358-364.
doi…
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psnet.ahrq.gov/node/73652/psn-pdf
September 01, 2021 - Dimensions of safety culture: a systematic review of
quantitative, qualitative and mixed methods for assessing
safety culture in hospitals.
September 1, 2021
Churruca K, Ellis LA, Pomare C, et al. Dimensions of safety culture: a systematic review of quantitative,
qualitative and mixed methods for assessing safety …
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psnet.ahrq.gov/node/867390/psn-pdf
December 18, 2024 - Quality of care and quality of life: balancing patient safety
and physician burnout.
December 18, 2024
Minkoff H, O'Brien J, Berkowitz R. Quality of care and quality of life: balancing patient safety and physician
burnout. Obstet Gynecol. 2024;144(3):e50-e55. doi:10.1097/aog.0000000000005681.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/36843/psn-pdf
January 05, 2017 - Improving medication reconciliation in the outpatient
setting.
January 5, 2017
Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm
J Qual Patient Saf. 2007;33(5):286-92.
https://psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
The Jo…
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psnet.ahrq.gov/node/45613/psn-pdf
September 01, 2018 - Patients as partners in learning from unexpected events.
September 1, 2018
Etchegaray J, Ottosen M, Aigbe A, et al. Patients as Partners in Learning from Unexpected Events. Health
Serv Res. 2016;51 Suppl 3:2600-2614. doi:10.1111/1475-6773.12593.
https://psnet.ahrq.gov/issue/patients-partners-learning-unexpected-eve…