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psnet.ahrq.gov/issue/using-safety-ii-and-resilient-healthcare-principles-learn-never-events
February 20, 2019 - approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United … April 30, 2014
Surgical never events in the United States.
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psnet.ahrq.gov/issue/care-compare
May 26, 2021 - through the provision of publicly available information on the quality of health care service in the United … States.
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psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
August 20, 2018 - hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United … States. … 2019
Prevention of prescription opioid misuse and projected overdose deaths in the United … States.
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psnet.ahrq.gov/issue/evaluation-association-between-hospital-survey-patient-safety-culture-hsops-measures-and
December 21, 2017 - infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United … States. … September 19, 2012
Clostridium Difficile infection in the United States: a national study
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Association between state medical malpractice environment and postoperative outcomes in the United … States. … 2019
Underlying reasons associated with hospital readmission following surgery in the United … States.
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psnet.ahrq.gov/node/855088/psn-pdf
January 01, 2024 - Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the
United … States.
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Health equity among Black women in the United States. … From a care standpoint, it is more complex because of our fragmented medical system in the United States … The fragmentation of care that patients receive in the United States has made it difficult to measure … It is worth noting however, that maternity care is typically a bundled cost in the United States and … Here in the United States, different OB/GYN practices use different electronic medical records (EMRs)
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - armamentarium of more than 10,000 prescription medications, and nearly one-third of adults
in the United … States take 5 or more medications. … adverse-drug-events-ambulatory-care
https://psnet.ahrq.gov/issue/increases-drug-and-opioid-overdose-deaths-united-states … partnership-patients
https://psnet.ahrq.gov/issue/cdc-clinical-practice-guideline-prescribing-opioids-pain-united-states
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Gregory, MD, MPH The United States spends more than any other country on hospital-based maternity care … Obstetric hemorrhage remains a common event and the most preventable cause of maternal mortality in the United … States and worldwide. … Pregnancy-related mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130:366-373. … Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly
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psnet.ahrq.gov/issue/transformational-effort-patient-safety
October 05, 2022 - together topic experts to summarize important issues for the consideration of the President of the United … States.
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psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
September 14, 2022 - the project as the Department reassesses issues that have arisen during test rollouts in several United … States hospitals.
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psnet.ahrq.gov/issue/aging-stigma-and-health-us-adults-over-65-what-do-we-know
December 23, 2020 - insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United … States, 2012-2017. … September 28, 2022
Medication errors and processes to reduce them in care homes in the United
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - This perspective examines the troubling decline in maternal health outcomes in the United … The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United … States. … This perspective examines the troubling decline in maternal health outcomes in the United … States.
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psnet.ahrq.gov/issue/millions-people-used-tainted-breathing-machines-fda-failed-use-its-power-protect-them
June 28, 2023 - This news story summarizes an investigative effort to identify weaknesses in the United States medical
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psnet.ahrq.gov/node/36442/psn-pdf
July 23, 2023 - Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration
by the United … States Department of Defense and AHRQ in order to support effective communication and
teamwork in health
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - In the United States oxygen cylinders are color-coded green, but in some other countries oxygen cylinders … Oxygen hoses in the United States are green and nitrous oxide hoses are blue, but the color coding for … The rules and regulations that govern this process in the United States are defined in the NFPA 99 Handbook … In the United States, oxygen is green, nitrous oxide is blue, and carbon dioxide is grey. … States are green; clinicians need to know the color-code for cylinders and gas hoses in their country
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - study found that just 3% of physicians accounted for 49% of all complaints filed by patients, and a United … States study found that 1% of physicians accounted for 32% of all malpractice complaints over a 10- … Unfortunately, states vary considerably in the rate of both major and minor disciplinary actions taken … Most health care organizations, and many states, mandate that health professionals formally report colleagues … April 12, 2023
Patient safety functions of state medical boards in the United States.
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psnet.ahrq.gov/issue/problem-list-completeness-electronic-health-records-multi-site-study-and-assessment-success
April 29, 2018 - This international study examined 10 health care organizations that use different EHRs in the United … States, United Kingdom, and Argentina.
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psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
July 29, 2020 - summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United … States, and research exploring the impact of apology laws on malpractice claims and patient outcomes
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psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging
June 18, 2021 - More than 70 million CT scans are performed in the United States every year, and the radiation exposure