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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/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/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/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/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/40553/psn-pdf
June 22, 2011 - Applying the Universal Protocol to improve patient safety
in radiology services.
June 22, 2011
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
https://psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services
Exploring causes of wrong-site, wrong patient, and wrong procedure errors i…
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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/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/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/perspective/patient-and-family-roles-safety
June 14, 2023 - Families on Safe Patient Care
As essential members of the care team, families play a critical role in reducing … the neonatal context, the importance of parental interaction with neonates is well established for reducing … and family anxiety, so it is likely that pandemic restrictions, which have shown variable efficacy in reducing … Johnson about The Role of Patient's Family In Reducing Harm
June 14, 2023
Editor’s note:
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - harm as a result 13 ; use of evidence-based care can help avoid “toxic cascades” of unnecessary tests, reducing … Healthcare Should Be Timely – Facilitating access to care; reducing waits and harmful delays for those … context of the community and family. 20 Timeliness is the ability to provide care at the right time, reducing … Settings by Engaging Patients and Families Toolkit for Engaging Patients to Improve Diagnostic Safety Reducing
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - harm as a result 13 ; use of evidence-based care can help avoid “toxic cascades” of unnecessary tests, reducing … Healthcare Should Be Timely – Facilitating access to care; reducing waits and harmful delays for those … context of the community and family. 20 Timeliness is the ability to provide care at the right time, reducing … Settings by Engaging Patients and Families Toolkit for Engaging Patients to Improve Diagnostic Safety Reducing
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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - In a review of recommendations for reducing workforce exposure,
investigators identified a set of six … healthcare facilities that are recommended to
be included in any approach to improve practices for reducing
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psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
October 13, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours
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Organization:
Organization
National Institute for Occupational Safety and Health (…
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psnet.ahrq.gov/node/39793/psn-pdf
August 25, 2010 - Infection Control in the Intensive Care Unit.
August 25, 2010
Crit Care Med. 2010;38:S265-S404.
https://psnet.ahrq.gov/issue/infection-control-intensive-care-unit
Articles in this special issue describe strategies to reduce infections in the intensive care unit, including
human factors design, guideline use…
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psnet.ahrq.gov/node/41831/psn-pdf
December 31, 2012 - The economics of health care quality and medical errors.
December 31, 2012
Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health
Care Finance. 2012;39(1):39-50.
https://psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors
Discussing the financia…
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psnet.ahrq.gov/node/36077/psn-pdf
July 05, 2006 - Perinatal patient safety from the perspective of nurse
executives: a round table discussion.
July 5, 2006
Thorman KE; Capitulo KL; Dubow J; Hanold K; Noonan M; Wehmeyer J.
https://psnet.ahrq.gov/issue/perinatal-patient-safety-perspective-nurse-executives-round-table-discussion
The authors summarize a discussion be…
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psnet.ahrq.gov/node/40406/psn-pdf
February 13, 2018 - Critical conversations: a call for a nonprocedural "time
out."
February 13, 2018
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp
Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
https://psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
This…
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psnet.ahrq.gov/node/34621/psn-pdf
September 27, 2017 - Human Factors and Medical Devices.
September 27, 2017
Center for Devices and Radiological Health, US Food and Drug Administration.
https://psnet.ahrq.gov/issue/human-factors-and-medical-devices
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with
use error. The U.S. …
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psnet.ahrq.gov/node/41508/psn-pdf
July 11, 2012 - Complications in surgery: root cause analysis and
preventive measures.
July 11, 2012
Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast
Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0.
https://psnet.ahrq.gov/issue/complications-surgery-root-cause…