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psnet.ahrq.gov/node/40937/psn-pdf
November 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated
Infections, Fiscal Year 2011.
November 16, 2011
Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09-
P013-4-E.
https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011
This annou…
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psnet.ahrq.gov/node/36798/psn-pdf
March 09, 2009 - Organizational culture, critical success factors, and the
reduction of hospital errors.
March 9, 2009
Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of
hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.07.005.
https://psnet.ahrq.gov/issue/o…
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psnet.ahrq.gov/node/36793/psn-pdf
August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic
surgeons.
August 26, 2011
Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med
Assoc. 2007;106(3):212-6.
https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons
The researchers surveyed Taiwanese…
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psnet.ahrq.gov/node/35891/psn-pdf
May 03, 2006 - Costs and Benefits of Health Information Technology.
May 3, 2006
Shekelle PG, Morton SC, Keeler EB. Rockville, MD: Agency for Healthcare Research and Quality; April
2006. AHRQ Publication No. 06-E006.
https://psnet.ahrq.gov/issue/costs-and-benefits-health-information-technology
The authors reviewed the literature …
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psnet.ahrq.gov/node/37743/psn-pdf
June 06, 2008 - Incidence and prevention of iatrogenic urethral injuries.
June 6, 2008
Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol.
2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108.
https://psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-ureth…
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psnet.ahrq.gov/node/50584/psn-pdf
October 23, 2019 - Unprotected: broken promises in Georgia’s senior care
industry.
October 23, 2019
Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019.
https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry
Assisted living facilities have challenges that reduce the quality and saf…
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psnet.ahrq.gov/node/41447/psn-pdf
May 30, 2012 - Massachusetts hospitals launch patient apology program.
May 30, 2012
Gallegos A.
https://psnet.ahrq.gov/issue/massachusetts-hospitals-launch-patient-apology-program
This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to
reduce liability lawsuits.
https://psnet.ahrq…
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psnet.ahrq.gov/node/34925/psn-pdf
February 27, 2009 - Medication errors and professional practice of registered
nurses.
February 27, 2009
Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33.
https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses
This Australian study identified and…
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psnet.ahrq.gov/node/41636/psn-pdf
August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff.
August 29, 2012
Eisler P. USA Today. August 16, 2012.
https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff
This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence
of hospital-acq…
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psnet.ahrq.gov/node/37654/psn-pdf
September 24, 2010 - The road to zero preventable birth injuries.
September 24, 2010
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf.
2008;34(4):201-205.
https://psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
This article reports how a perinatal safety team, which …
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psnet.ahrq.gov/node/39255/psn-pdf
February 02, 2011 - The patient who falls: "It's always a trade-off."
February 2, 2011
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66.
doi:10.1001/jama.2009.2024.
https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
Through a case study, this article reviews evidence on risk…
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psnet.ahrq.gov/node/36533/psn-pdf
May 27, 2011 - Effect of computerisation on the quality and safety of
chemotherapy prescription.
May 27, 2011
Voeffray M, Pannatier A, Stupp R, et al. Effect of computerisation on the quality and safety of
chemotherapy prescription. Qual Saf Health Care. 2006;15(6):418-21.
https://psnet.ahrq.gov/issue/effect-computerisation-qual…
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psnet.ahrq.gov/node/38709/psn-pdf
June 17, 2009 - Enteral feeding misconnections: an update.
June 17, 2009
Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract.
2009;24(3):325-34. doi:10.1177/0884533609335174.
https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update
This review surveys information on enteral nutriti…
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psnet.ahrq.gov/node/41562/psn-pdf
August 01, 2012 - The Final Check: Say it Out Loud.
August 1, 2012
https://psnet.ahrq.gov/issue/final-check-say-it-out-loud
This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just
culture concepts.
https://psnet.ahrq.gov/issue/final-check-say-it-out-loud
https://psnet.ahrq.gov/web-mm/ri…
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psnet.ahrq.gov/node/60216/psn-pdf
April 08, 2020 - The Diagnosis of Ectopic Pregnancy.
April 8, 2020
Farnborough, UK: Healthcare Safety Investigation Branch; March 2020.
https://psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy
Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child.
This report analyzes a dela…
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psnet.ahrq.gov/node/38992/psn-pdf
April 16, 2018 - Safe patient outcomes occur with timely, standardized
communication of critical values.
April 16, 2018
https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-
values
This article reports on failures surrounding critical test results and describes mechanisms to standardi…
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psnet.ahrq.gov/node/39484/psn-pdf
April 28, 2010 - Surgical fires, a clear and present danger.
April 28, 2010
Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92.
doi:10.1016/j.surge.2010.01.005.
https://psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger
This article reviews the literature on surgical fires and …
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psnet.ahrq.gov/node/42596/psn-pdf
October 23, 2013 - Diagnostic Errors and Strategies to Minimize Them.
October 23, 2013
Cutrer WB, Sullivan WM, Fleming AE, et al. Curr Probl Pediatr Adolesc Health Care. 2013;43:225-257.
https://psnet.ahrq.gov/issue/diagnostic-errors-and-strategies-minimize-them
Articles in this special issue cover diagnostic errors, includin…
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digital.ahrq.gov/principal-investigator/mcculloch-michael
January 01, 2023 - McCulloch, Michael
Improving Pediatric Donor Heart Utilization with Predictive Analytics
Description
This study aims to optimize the use of donor hearts for infants and children awaiting heart transplantation by developing predictive models to assess in real-time the potential…
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digital.ahrq.gov/principal-investigator/porter-michael
January 01, 2023 - Porter, Michael
Improving Pediatric Donor Heart Utilization with Predictive Analytics
Description
This study aims to optimize the use of donor hearts for infants and children awaiting heart transplantation by developing predictive models to assess in real-time the potential fo…