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psnet.ahrq.gov/issue/middle-ground-public-accountability
March 02, 2011 - Commentary
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A middle ground on public accountability.
Citation Text:
Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med. 2004;350(23):2409-2412.
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psnet.ahrq.gov/issue/safe-use-health-information-technology
December 23, 2016 - Sentinel Event Alerts
Safe use of health information technology.
Citation Text:
Safe use of health information technology. Sentinel Event Alert. March 31, 2015;(54):1-6.
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psnet.ahrq.gov/node/40618/psn-pdf
August 27, 2012 - Predictors of likelihood of speaking up about safety
concerns in labour and delivery.
August 27, 2012
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799.
doi:10.1136/bmjqs.2010.050211.
https://psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-deli…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. 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/issue/making-dialysis-safer-patients-coalition
April 06, 2022 - Government Resource
Making Dialysis Safer for Patients Coalition.
Citation Text:
Making Dialysis Safer for Patients Coalition. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/electronic-health-record-adoption-childrens-hospitals-united-states
February 17, 2011 - Study
Electronic health record adoption by children's hospitals in the United States.
Citation Text:
Nakamura MM, Ferris T, DesRoches CM, et al. Electronic health record adoption by children's hospitals in the United States. Arch Pediatr Adolesc Med. 2010;164(12):1145-51. doi:10.1001/arc…
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psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning
June 19, 2018 - Commentary
The problem with…using stories as a source of evidence and learning.
Citation Text:
Iedema R. The problem with … using stories as a source of evidence and learning. BMJ Qual Saf. 2022;31(3):234-237. doi:10.1136/bmjqs-2021-014221.
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psnet.ahrq.gov/issue/systematic-review-behavioural-marker-systems-healthcare-what-do-we-know-about-their
January 23, 2019 - Review
A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application?
Citation Text:
Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in healthcare: what do we know about their a…
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psnet.ahrq.gov/issue/optimizing-situation-awareness-reduce-emergency-transfers-hospitalized-children
January 19, 2022 - Study
Optimizing situation awareness to reduce emergency transfers in hospitalized children.
Citation Text:
Sosa T, Sitterding M, Dewan M, et al. Optimizing situation awareness to reduce emergency transfers in hospitalized children. Pediatrics. 2021;148(4):e2020034603. doi:10.1542/peds.2…
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psnet.ahrq.gov/issue/does-physicians-training-induce-overconfidence-hampers-disclosing-errors
October 21, 2009 - Study
Does physician's training induce overconfidence that hampers disclosing errors?
Citation Text:
Brezis M, Orkin-Bedolach Y, Fink D, et al. Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors? J Patient Saf. 2019;15(4):296-298. doi:10.1097/PTS.0000000000000…
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psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
March 18, 2019 - Commentary
Classic
Five years after 'To Err is Human': what have we learned?
Citation Text:
Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90.
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psnet.ahrq.gov/issue/applying-requisite-imagination-safeguard-electronic-health-record-transitions
August 25, 2021 - Commentary
Applying requisite imagination to safeguard electronic health record transitions.
Citation Text:
Sittig DF, Lakhani P, Singh H. Applying requisite imagination to safeguard electronic health record transitions. J Am Med Inform Assoc. 2022;29(5):1014-1018. doi:10.1093/jamia/ocab…
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psnet.ahrq.gov/issue/impact-safety-organizing-trusted-leadership-and-care-pathways-reported-medication-errors
January 18, 2011 - Study
The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.
Citation Text:
Vogus TJ, Sutcliffe K. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital n…
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psnet.ahrq.gov/issue/speaking-about-dangers-hidden-curriculum
September 30, 2020 - Commentary
Speaking up about the dangers of the hidden curriculum.
Citation Text:
Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff (Millwood). 2014;33(1):168-171. doi:10.1377/hlthaff.2013.1073.
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psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds
January 02, 2017 - Study
Classic
Patient Safety Leadership WalkRounds.
Citation Text:
Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1). doi:10.1016/s1549-3741(03)29003-1.
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psnet.ahrq.gov/issue/model-patient-how-simulators-are-changing-way-doctors-are-trained
August 24, 2016 - Newspaper/Magazine Article
A model patient: how simulators are changing the way doctors are trained.
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February 8, 2011
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psnet.ahrq.gov/issue/ihi-announces-hospitals-participating-100000-lives-campaign-have-saved-estimated-122300-lives
August 07, 2024 - Press Release/Announcement
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IHI announces that hospitals participating in 100,000 Lives Campaign have saved an estimated 122,300 lives.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-8
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/36398/psn-pdf
November 08, 2006 - When a heart attack goes undiagnosed.
November 8, 2006
Davis R. USA Today. Oct 2006.
https://psnet.ahrq.gov/issue/when-heart-attack-goes-undiagnosed
This article shares stories of missed heart attack diagnoses and is accompanied by an online poll for
readers to share their experiences with medical error.
https://…