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psnet.ahrq.gov/node/836843/psn-pdf
April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated
checklist for clinical decision support during PICU daily
rounds.
April 7, 2022
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist
for clinical decision support during PICU daily rounds. Pediatr Crit Care…
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psnet.ahrq.gov/node/39329/psn-pdf
September 30, 2015 - Safe Patients, Smart Hospitals: How One Doctor's
Checklist Can Help Us Change Health Care from the
Inside Out.
September 30, 2015
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
https://psnet.ahrq.gov/issue/safe-patients-smart-hospitals-how-one-doctors-checklist-can-help-us-chang…
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psnet.ahrq.gov/issue/ecri-guidelines-trust
March 10, 2021 - Database/Directory
ECRI Guidelines Trust.
Citation Text:
ECRI Guidelines Trust. ECRI Institute.
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November 28,…
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psnet.ahrq.gov/issue/massachusetts-coalition-prevention-medical-errors
February 05, 2014 - Multi-use Website
Massachusetts Coalition for the Prevention of Medical Errors.
Citation Text:
Massachusetts Coalition for the Prevention of Medical Errors. Massachusetts Coalition for the Prevention of Medical Errors
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psnet.ahrq.gov/issue/safer-patients-network
May 12, 2021 - Multi-use Website
Safer Patients Network.
Citation Text:
Safer Patients Network. The Health Foundation.
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psnet.ahrq.gov/issue/patientfamily-crisis-hotline
December 02, 2020 - Multi-use Website
Patient/Family Crisis Hotline.
Citation Text:
Patient/Family Crisis Hotline. Sorry Works!
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psnet.ahrq.gov/issue/leapfrog-hospital-safety-scores-depressing
November 13, 2013 - Newspaper/Magazine Article
Leapfrog hospital safety scores 'depressing.'
Citation Text:
Leapfrog hospital safety scores 'depressing.' Clark C. HealthLeaders Media. May 9, 2013.
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psnet.ahrq.gov/issue/critical-thinking
August 22, 2007 - Special or Theme Issue
Critical Thinking.
Citation Text:
Critical Thinking. Theor Issues Ergon Sci. 2011;12:204-272.
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psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
February 06, 2008 - Newspaper/Magazine Article
The best medicine for fixing the modern hospital.
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December 12, 2012
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psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-safety-after-cyberattack
March 13, 2024 - Sentinel Event Alerts
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.
Citation Text:
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006.
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psnet.ahrq.gov/issue/non-english-speakers-find-ers-hard-reach
January 18, 2023 - Newspaper/Magazine Article
Non-English speakers find ERs hard to reach.
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October 26, 2007
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psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-recognition-software
July 10, 2024 - Newspaper/Magazine Article
Can we ensure medication safety with the use of speech recognition software?
Citation Text:
Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety Alert! Acute Care. August 22, 2024;29(17):1-3.
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psnet.ahrq.gov/node/42064/psn-pdf
March 16, 2013 - Making Health Care Safer: A Critical Review of Modern
Evidence Supporting Strategies to Improve Patient Safety.
March 16, 2013
Shekelle PG, Pronovost PJ, Wachter RM, Rao JK, Mulrow CD, eds. Ann Intern Med. 2013;158(5 Pt 2):365-
440.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-review-moder…
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psnet.ahrq.gov/node/45206/psn-pdf
October 17, 2017 - Evaluation of the association between Hospital Survey on
Patient Safety Culture (HSOPS) measures and catheter-
associated infections: results of two national
collaboratives.
October 17, 2017
Meddings J, Reichert H, Greene T, et al. Evaluation of the association between Hospital Survey on Patient
Safety Culture (H…
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psnet.ahrq.gov/issue/im-sorry-why-so-hard-doctors-say
November 10, 2010 - Newspaper/Magazine Article
"I'm sorry": Why is that so hard for doctors to say?
Citation Text:
"I'm sorry": Why is that so hard for doctors to say? O'Reilly KB.
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psnet.ahrq.gov/issue/patient-safety-risk-and-quality
March 10, 2021 - Multi-use Website
Patient Safety, Risk and Quality.
Citation Text:
Patient Safety, Risk and Quality. ECRI
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Se…
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. 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/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…