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psnet.ahrq.gov/node/39182/psn-pdf
May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in
obstetrics and gynecology.
May 22, 2019
Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in
obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e.
https://psnet.ahrq.gov/issue/acog-com…
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psnet.ahrq.gov/node/40502/psn-pdf
January 01, 2020 - New 2012 National Patient Safety Goal - catheter-
associated urinary tract infection (CAUTI).
June 1, 2011
Joint Commission.
https://psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract-
infection-cauti
This announcement reveals the new National Patient Safety Goal for 2012…
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psnet.ahrq.gov/node/45544/psn-pdf
December 19, 2016 - Prescribing errors that cause harm.
December 19, 2016
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
https://psnet.ahrq.gov/issue/prescribing-errors-cause-harm
Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year
period, t…
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psnet.ahrq.gov/node/42228/psn-pdf
October 08, 2013 - Cognitive diagnostic error in internal medicine.
October 8, 2013
Van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med.
2013;24(6):525-9. doi:10.1016/j.ejim.2013.03.006.
https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine
This review discusses how confir…
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psnet.ahrq.gov/node/39807/psn-pdf
December 29, 2014 - Perspectives in quality: designing the WHO Surgical
Safety Checklist.
December 29, 2014
Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety
Checklist. Int J Qual Health Care. 2010;22(5):365-70. doi:10.1093/intqhc/mzq039.
https://psnet.ahrq.gov/issue/perspectives-qual…
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psnet.ahrq.gov/node/60948/psn-pdf
September 23, 2020 - Without an 'ounce of empathy': their stories show the
dangers of being Black and pregnant.
September 23, 2020
Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.
https://psnet.ahrq.gov/issue/without-ounce-empathy-their-stories-show-dangers-being-black-and-pregnant
Implicit and explicit biases …
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psnet.ahrq.gov/node/851660/psn-pdf
July 26, 2023 - From aviation to pediatric surgery.
July 26, 2023
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila).
2024;63(4):557-559. doi:10.1177/00099228231176631.
https://psnet.ahrq.gov/issue/aviation-pediatric-surgery
Human factors strategies are increasingly applied in health …
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psnet.ahrq.gov/node/40865/psn-pdf
September 12, 2016 - A review of current and emerging approaches to address
failure-to-rescue.
September 12, 2016
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-
rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
https://psnet.ahrq.gov/issue/review-current-…
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psnet.ahrq.gov/node/50878/psn-pdf
February 05, 2020 - The role of racism as a core patient safety issue.
February 5, 2020
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-
61.
https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
A variety of biases can reduce the effectiveness and safety of care.…
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psnet.ahrq.gov/node/39576/psn-pdf
September 25, 2010 - Taking Care of Myself: A Guide for When I Leave the
Hospital.
September 25, 2010
Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
https://psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital
This guide provides patients with information they need t…
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psnet.ahrq.gov/node/45990/psn-pdf
August 24, 2022 - Medication Safety Certificate Program.
August 24, 2022
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/medication-safety-certificate-program
Leadership commitment to reduce medication errors can help address this safety problem. This certificate
…
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psnet.ahrq.gov/node/44875/psn-pdf
March 02, 2016 - "Teach-back" from a patient's perspective.
March 2, 2016
Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4.
doi:10.1097/01.NURSE.0000476249.18503.f5.
https://psnet.ahrq.gov/issue/teach-back-patients-perspective
The teach-back method, having patients repeat i…
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psnet.ahrq.gov/node/38453/psn-pdf
January 02, 2017 - A multidisciplinary team approach to retained foreign
objects.
January 2, 2017
Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects.
Jt Comm J Qual Saf. 2009;35(3):123-132.
https://psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects
Th…
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psnet.ahrq.gov/node/60264/psn-pdf
January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert!
January 14, 2021
March 2020--January 2021.
https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert
Medication safety is improved through the sharing of frontline improvement experiences and concerns.
These articles share recommendations to…
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psnet.ahrq.gov/node/60262/psn-pdf
April 22, 2020 - COVID-19 exposes potential gaps in PPE training,
effectiveness.
April 22, 2020
Ault A. Medscape Medical News. April 6, 2020.
https://psnet.ahrq.gov/issue/covid-19-exposes-potential-gaps-ppe-training-effectiveness
Training is essential to ensure the safe use of equipment. This article discusses how the incorrect us…
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psnet.ahrq.gov/node/40868/psn-pdf
October 19, 2011 - Simulation to enhance patient safety: why aren't we there
yet?
October 19, 2011
Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest.
2011;140(4):854-858. doi:10.1378/chest.11-0728.
https://psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet
Discussin…
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psnet.ahrq.gov/node/41053/psn-pdf
December 30, 2014 - Time to accelerate integration of human factors and
ergonomics in patient safety.
December 30, 2014
Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in
patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421.
https://psnet.ahrq.gov/issue/time-acc…
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psnet.ahrq.gov/node/846165/psn-pdf
March 15, 2023 - Do no unconscious harm.
March 15, 2023
Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698.
https://psnet.ahrq.gov/issue/do-no-unconscious-harm
Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and
patient/physician commun…
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psnet.ahrq.gov/node/39558/psn-pdf
May 26, 2010 - ReCASTing the RCA: an improved model for performing
root cause analyses.
May 26, 2010
Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root
Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533.
https://psnet.ahrq.gov/issue/recasting-…
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psnet.ahrq.gov/node/45338/psn-pdf
July 20, 2016 - Understanding models of error and how they apply in
clinical practice.
July 20, 2016
Garfield S, Franklin BD. Pharm J. June 14, 2016.
https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
Human error and fallibility are a part of health care delivery that can be exacerbated b…