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psnet.ahrq.gov/issue/fixing-broken-healthcare-system
August 01, 2018 - Commentary
Fixing a broken healthcare system.
Citation Text:
Fixing a broken healthcare system. Delbanco SF.
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psnet.ahrq.gov/issue/medical-errors-overcoming-challenges
September 29, 2017 - Commentary
Medical errors: overcoming the challenges.
Citation Text:
Kalra J. Medical errors: overcoming the challenges. Clin Biochem. 2004;37(12):1063-71.
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psnet.ahrq.gov/issue/selling-soap
March 06, 2005 - Image/Poster
Selling soap.
Citation Text:
Selling soap. Dubner SJ; Levitt SD.
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August 5, 2008
Dubner …
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-research-funded-projects
December 24, 2008 - Government Resource
Improving Patient Safety Through Simulation Research: Funded Projects.
Citation Text:
Improving Patient Safety Through Simulation Research: Funded Projects. Agency for Healthcare Quality and Research; AHRQ.
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psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
April 23, 2014 - Toolkit
Improving Patient Safety Culture – A Practical Guide.
Citation Text:
Improving Patient Safety Culture – A Practical Guide. London, UK: NHS England; July 2023.
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psnet.ahrq.gov/issue/improvement-cymru
October 20, 2014 - Multi-use Website
Improvement Cymru.
Citation Text:
Improvement Cymru. NHS Wales.
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July 10, 2012
NHS …
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psnet.ahrq.gov/issue/why-worry-about-near-misses
February 11, 2014 - Newspaper/Magazine Article
Why worry about near misses?
Citation Text:
Why worry about near misses? Marella WM.
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psnet.ahrq.gov/issue/critical-behavior-improve-quality-and-patient-safety-health-care-speaking
March 13, 2019 - Review
As a critical behavior to improve quality and patient safety in health care: speaking up!
Citation Text:
Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety in Health. 2016;2(1). doi:10.1186/s40886-016-0021-x.
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psnet.ahrq.gov/issue/2005-annual-patient-safety-and-health-information-technology-conference-making-health-care
December 24, 2008 - Slideset
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Citation Text:
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer throug…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
November 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Treatment Challenges After Discharge
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Source and Credits
This presentation is based on the November 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Chase Coffey, MD, Henry Ford Health System,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
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*
Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
February 01, 2013 - Spotlight Case July 2008
Spotlight Case
Delay in Treatment:
Failure to Contact Patient Leads to Significant Complications
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*
Source and Credits
This presentation is based on the February 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: …
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Pharmacist's Role in Medication Safety
Citation Text:
The Pharmacist's Role in Medication Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Root Cause Analysis
Citation Text:
Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/851869/psn-pdf
July 31, 2023 - Building Capacity for Patient Safety
July 31, 2023
Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/building-capacity-patient-safety
In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/50858/psn-pdf
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
Definition of Artificial Intelligence
The definition of artificial intelligence (…
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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…