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psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - For example, data from the Lexington
Veteran Affairs Medical Center and the University of Michigan's
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - In two studies conducted by the United States
Veterans Affairs Medical Centers between 2001 and 2009
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2015. 20.
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - //psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - patient incidents accounted for 4% of all medication errors.( 3 ) During a recent 3-year period, the Veterans … Affairs National Center for Patient Safety received more than 100 patient misidentification root cause
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psnet.ahrq.gov/node/33677/psn-pdf
November 01, 2008 - psnet.ahrq.gov//#ref15
https://psnet.ahrq.gov//#ref16
https://psnet.ahrq.gov//#ref17
In a survey of Veterans … Affairs hospitals, Saint and colleagues document variable but, overall, relatively
limited implementation
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - Results
of a Department of Veterans Affairs Cooperative Study.
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - August 17, 2022
Retrospective analysis of reported suicide deaths and attempts on Veterans … September 19, 2016
Inpatient suicide on mental health units in Veterans Affairs (VA)
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Management Policy and Performance: Hearings of the Subcommittee on Health of the
House Committee on Veterans … ’ Affairs, 105th Cong, 1st Sess.
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - DeBakey Veterans Affairs Medical Center and the Section of Health Services Research
Department of Medicine
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Lederle FA, Wilson SE, Johnson GR, et al; Aneurysm Detection and Management Veterans Affairs
Cooperative
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Indeed, one early study that described the RCA process within the Veterans Affairs health system did
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - Results of a Department of Veterans Affairs Cooperative Study.
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - Department of Veterans Affairs: a qualitative analysis.
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - strikingly successful early efforts in safety, quality, and
computerization at the US Department of Veterans … Affairs (VA), recently lamented that the VA's system is
becoming more rule-bound and bureaucratic,
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
Editor, AHRQ WebM
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - Filice, MD Chief, Infectious Disease Section, Veterans Affairs Medical Professor of Medicine
University
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - The Veterans Affairs shift change physician-to-physician handoff
project.
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Langone Medical Center New York, New York Lewis Nelson, MD Professor and Vice Chair for Academic Affairs … Related Resources
Medication safety events after acute myocardial infarction among veterans