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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Patient Safety During Hospital Discharge
Katherine Liang and Eric Alper, MD | April 1, 2018
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Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions
Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD
| November 16, 2022
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD
November 16, 2022
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Citation Text:
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
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Citation Text:
Baker DP, King HB, Battles J. New Ins…
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
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Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
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Citation Text:
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - Team-Developed Care Plan and Ongoing Care
Management by Social Workers and Nurse Practitioners
Result in Better Outcomes and Reduced Acute Care
Utilization in Low-Income Seniors and other High-Risk
Populations
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovatio…
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
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Citation Text:
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - SPOTLIGHT CASE
The Missing Suction Tip
Citation Text:
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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