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psnet.ahrq.gov/node/862152/psn-pdf
February 07, 2024 - Risk identification and prediction of complaints and
misconduct against health practitioners: a scoping
review.
February 7, 2024
Wang Y, Ram SS, Scahill S. Risk identification and prediction of complaints and misconduct against health
practitioners: a scoping review. Int J Qual Health Care. 2024;36(1):mzad114. doi…
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psnet.ahrq.gov/node/45000/psn-pdf
August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical
Access Hospital (CAH) Changes to Promote Innovation,
Flexibility, and Improvement in Patient Care; Proposed
Rule.
June 29, 2016
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
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psnet.ahrq.gov/node/45763/psn-pdf
December 19, 2017 - Expanded pharmacy technician roles: accepting verbal
prescriptions and communicating prescription transfers.
December 19, 2017
Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and
communicating prescription transfers. Res Social Adm Pharm. 2017;13(6):1191-1195.
doi:10.1016/j.s…
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psnet.ahrq.gov/node/35726/psn-pdf
February 09, 2011 - Sleep deprivation and clinical performance.
February 9, 2011
Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002;287(8):955-7.
https://psnet.ahrq.gov/issue/sleep-deprivation-and-clinical-performance
This review discusses evidence for the role sleep deprivation plays on performance in…
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psnet.ahrq.gov/node/73257/psn-pdf
December 01, 2021 - Peer Review of a Report on Strategies to Improve Patient
Safety.
May 12, 2021
Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN:
9780309462808.
https://psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety
The Patient Safety and Quality Improvement Act of 200…
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psnet.ahrq.gov/node/46190/psn-pdf
August 17, 2017 - Preventing harm in the ICU—building a culture of safety
and engaging patients and families.
August 17, 2017
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and
Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537.
doi:10.1097/CCM.0000000000002556.
ht…
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psnet.ahrq.gov/node/73280/psn-pdf
May 19, 2021 - Rates of serious surgical errors in California and plans to
prevent recurrence.
May 19, 2021
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent
recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058.
https://psnet.ahrq.gov/issue/rates-…
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psnet.ahrq.gov/node/46375/psn-pdf
November 29, 2017 - Fall risk and prevention agreement: engaging patients
and families with a partnership for patient safety.
November 29, 2017
Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership
for patient safety. BMJ Open Qual. 2017;6(2):e000038. doi:10.1136/bmjoq-2017-000038.
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April 27, 2022 - Does a suggested diagnosis in a general practitioners'
referral question impact diagnostic reasoning: an
experimental study.
April 27, 2022
Staal J, Speelman M, Brand R, et al. Does a suggested diagnosis in a general practitioners’ referral
question impact diagnostic reasoning: an experimental study. BMC Med Educ.…
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psnet.ahrq.gov/node/46654/psn-pdf
December 13, 2017 - Organisational paradoxes in speaking up for safety:
implications for the interprofessional field.
December 13, 2017
Rowland P. Organisational paradoxes in speaking up for safety: Implications for the interprofessional field.
J Interprof Care. 2017;31(5):553-556. doi:10.1080/13561820.2017.1321305.
https://psnet.ahr…
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psnet.ahrq.gov/node/60927/psn-pdf
September 16, 2020 - Amid COVID-19, discipline against bad doctors plummets;
more medical errors may slip through cracks.
September 16, 2020
O'Donnell J. USA Today. September 8, 2020
https://psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-
may-slip-through
Management and clinical functio…
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psnet.ahrq.gov/node/862998/psn-pdf
February 21, 2024 - Exploring the factors that drive clinical negligence claims:
stated preferences of those who have experienced
unintended harm.
February 21, 2024
Wickramasekera N, Hole AR, Rowen D, et al. Exploring the factors that drive clinical negligence claims:
stated preferences of those who have experienced unintended harm. …
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psnet.ahrq.gov/node/47030/psn-pdf
June 06, 2018 - Creating a safer operating room: groups, team dynamics
and crew resource management principles.
June 6, 2018
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource
management principles. Semin Pediatr Surg. 2018;27(2):107-113. doi:10.1053/j.sempedsurg.2018.02.008.
https://p…
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psnet.ahrq.gov/node/72821/psn-pdf
March 10, 2019 - I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources.
March 10, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources. MedEdPORTAL. 2018;14(1):10736. doi:10.15766/mep_2374-
8265.10736.
https://psnet.ahr…
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psnet.ahrq.gov/node/34645/psn-pdf
December 23, 2008 - How do patients want physicians to handle mistakes? A
survey of internal medicine patients in an academic
setting.
December 23, 2008
Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of
internal medicine patients in an academic setting. Arch Intern Med. 1996;156(22):2565-9…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/state-key-drive-diagram.pdf
June 02, 2025 - Transcranial Doppler Screening for Children with Sickle Cell Anemia: State Medicaid Program - Key Driver Diagram
Transcranial Doppler Screening for Children with Sickle Cell Anemia
State Medicaid Program - Key Driver Diagram
Global Aim
To reduce the
incidence of
stroke in children
wi…
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psnet.ahrq.gov/node/46032/psn-pdf
May 03, 2017 - Leveraging the Partnership for Patients' initiative to
improve patient safety and quality within the Military
Health System.
May 3, 2017
King HB, Kesling K, Birk C, et al. Leveraging the Partnership for Patients' Initiative to Improve Patient
Safety and Quality Within the Military Health System. Mil Med. 2017;182(…
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psnet.ahrq.gov/node/73912/psn-pdf
October 06, 2021 - The Contribution of Diagnostic Errors to Maternal
Morbidity and Mortality During and Immediately After
Childbirth: State of the Science.
October 6, 2021
Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality;
September 2021. AHRQ Publication No. 20(21)-0040-6-EF.
https://ps…
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psnet.ahrq.gov/node/865341/psn-pdf
March 27, 2024 - Patients' and doctors' views and experiences of the
patient safety trajectory of breast cancer care.
March 27, 2024
Forrest C, O'Sullivan MJ, Ryan M, et al. Patients' and doctors’ views and experiences of the patient safety
trajectory of breast cancer care. Breast. 2024;75:103699. doi:10.1016/j.breast.2024.103699.
…
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September 01, 2018 - Changes in physician practice patterns after
implementation of a communication-and-resolution
program.
September 1, 2018
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of
a Communication-and-Resolution Program. Health Serv Res. 2016;51(Suppl 3):2516-2536.
doi:10.…