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psnet.ahrq.gov/node/837855/psn-pdf
August 17, 2022 - Patterns of error in interpretive pathology.
August 17, 2022
Packer MDC, Ravinsky E, Azordegan N. Patterns of error in interpretive pathology. Am J Clin Pathol.
2022;157(5):767-773. doi:10.1093/ajcp/aqab190.
https://psnet.ahrq.gov/issue/patterns-error-interpretive-pathology
Studies have shown diagnostic discordanc…
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psnet.ahrq.gov/node/44465/psn-pdf
November 20, 2015 - Why even good physicians do not wash their hands.
November 20, 2015
Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf.
2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319.
https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
Insufficient hand hygiene comp…
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psnet.ahrq.gov/node/50571/psn-pdf
October 23, 2019 - Medication errors in the context of hematopoietic stem
cell transplantation: a systematic review.
October 23, 2019
Lermontov SP, Brasil SC, de Carvalho MR. Medication Errors in the Context of Hematopoietic Stem Cell
Transplantation: A Systematic Review. Cancer Nurs. 2019;42(5):365-372.
doi:10.1097/NCC.000000000000…
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psnet.ahrq.gov/node/47133/psn-pdf
April 07, 2019 - "Doctor Jazz": lessons that medical professionals can
learn from jazz musicians.
April 7, 2019
van Ark AE, Wijnen-Meijer M. "Doctor Jazz": Lessons that medical professionals can learn from jazz
musicians. Med Teach. 2019;41(2):201-206. doi:10.1080/0142159X.2018.1461205.
https://psnet.ahrq.gov/issue/doctor-jazz-les…
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psnet.ahrq.gov/node/39959/psn-pdf
December 21, 2014 - Hospital process compliance and surgical outcomes in
Medicare beneficiaries.
December 21, 2014
Nicholas LH, Osborne NH, Birkmeyer JD, et al. Hospital process compliance and surgical outcomes in
medicare beneficiaries. Arch Surg. 2010;145(10):999-1004. doi:10.1001/archsurg.2010.191.
https://psnet.ahrq.gov/issue/hos…
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psnet.ahrq.gov/node/44196/psn-pdf
March 27, 2017 - Patient Safety in Ambulance Services: A Scoping Review.
March 27, 2017
Patient Safety In Ambulance Services: A Scoping Review.
https://psnet.ahrq.gov/issue/patient-safety-ambulance-services-scoping-review
The safety of emergency medical care delivered in conjunction with ambulance services has not been
studied in …
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psnet.ahrq.gov/node/866190/psn-pdf
June 26, 2024 - What is diagnostic safety? A review of safety science
paradigms and rethinking paths to improving diagnosis.
June 26, 2024
Choi JJ. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving
diagnosis. Diagnosis (Berl). 2024;11(4):369-373. doi:10.1515/dx-2024-0008.
https://ps…
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psnet.ahrq.gov/node/44585/psn-pdf
November 04, 2015 - Evaluation of near-miss wrong-patient events in radiology
reports.
November 4, 2015
Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient
Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339.
https://psnet.ahrq.gov/issue/evaluation-…
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psnet.ahrq.gov/node/837866/psn-pdf
August 17, 2022 - A System in Need of Repair: Addressing Organizational
Failures of the U.S.’s Organ Procurement and
Transplantation Network.
August 17, 2022
US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.
https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-
procurement…
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psnet.ahrq.gov/node/46222/psn-pdf
June 21, 2017 - Enhanced time out: an improved communication process.
June 21, 2017
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570.
doi:10.1016/j.aorn.2017.03.014.
https://psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
The Universal Protocol requires hospitals t…
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psnet.ahrq.gov/node/43385/psn-pdf
August 06, 2014 - Medicines management support to older people:
understanding the context of systems failure.
August 6, 2014
Rogers S, Martin G, Rai G. Medicines management support to older people: understanding the context of
systems failure. BMJ Open. 2014;4(7):e005302. doi:10.1136/bmjopen-2014-005302.
https://psnet.ahrq.gov/issu…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-20.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.20. Major Factors that Inhibit Lean Success
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case …
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integrationacademy.ahrq.gov/print/pdf/node/23253
View PDF
Center for Psychology & Health
View PDF
Website
https://www.apa.org/health
Mission
To promote the advancement, communication, and application of psychological science and knowledge to
benefit society and improve lives.
Location
Washington, DC
United States
Terms of Use
May require fee or membership
De…
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psnet.ahrq.gov/node/838255/psn-pdf
October 05, 2022 - Opportunities to Improve Patient Safety, Advancing U.S.
Innovation, and Innovation Hubs.
October 5, 2022
President’s Council of Advisors on Science and Technology. Washington, DC: White House; September
21, 2022.
https://psnet.ahrq.gov/issue/opportunities-improve-patient-safety-advancing-us-innovation-and-innovati…
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psnet.ahrq.gov/node/36734/psn-pdf
March 10, 2011 - Integrating incident reporting into an electronic patient
record system.
March 10, 2011
Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record
system. J Am Med Inform Assoc. 2007;14(2):175-81.
https://psnet.ahrq.gov/issue/integrating-incident-reporting-electronic…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-table6.pdf
June 02, 2025 - High-Risk Deliveries at Facilities with 24/7 In-House Blood Banking/Transfusion Services - Table 6
TABLE 6
HROB Summary (Combined Unduplicated)
New York State Medicaid, 2010
Urbanicity UIC N OB
Proxy1
Transfusion
Proxy2
NICU
>=33
URBAN
Large
Metropolitan
1 48,562 27.10% 14.62% 37.98%
Sm…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sicklecell-clinic-followup.pdf
June 02, 2025 - Sample Sickle Cell Clinic Follow-Up Care Process (2c.5)
Sample Sickle Cell Clinic Follow-Up Care Process (2c.5)
This diagram illustrates the process for reviewing the patient master list and identifying and contacting
individuals who require an annual TCD screen.
…
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma
Patient
April 27, 2022
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
Disclosure of Relevant Financial Relationship…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/visual-impairment-screening-1996
January 01, 1996 - Share to Facebook
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archived
Final Recommendation Statement
Visual Impairment: Screening, 1996
January 01, 1996
Recommendations made by the USPSTF are independent of the U.S. government. T…
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digital.ahrq.gov/sites/default/files/docs/artificial-intelligence-tools-improve-qa-03182025.pdf
March 18, 2025 - AHRQ National Webinar on Artificial Intelligence Tools to Improve Provider Effectiveness and Patient Outcomes – Questions and Answers
AHRQ National …