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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
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Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. 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/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Citation Text:
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 18, 2024 - Don’t Bite Your Tongue.
Citation Text:
Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - showcases how AI can link to
those processes and decisions that lead to improvements in unexpected ways
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - False positive results may harm the tested person and their
contacts in other ways, during a pandemic
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - handoffs has been reported for psychiatry ( 21 ), and it remains a growth area.( 22 )
Additional ways
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Patient navigators are an example of a skill-mix
innovation in which new tasks or ways of working are
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Five ways to respond to a medical mistake.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Patient navigators are an example of a skill-mix innovation in which new tasks or ways of working are
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Safety/MedWatch/
processes of care requires attention to inter-professional culture differences and ways
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - False positive results may harm the tested person and their contacts in other ways, during a pandemic
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - Not necessarily in severe ways,
but through the kinds of behaviors that frontline caregivers perceive … If you don't have equally transparent and equitable ways of judging and moving those
situations into … demonstrate that no matter
how you're paid, if you understand how you're paid, you can focus these tools in ways
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psnet.ahrq.gov/node/38108/psn-pdf
September 30, 2014 - No more blame & shame: developing event-reporting
systems may go a long way to reducing patient care
errors in EMS.
September 30, 2014
Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may
go a long way to reducing patient care errors in EMS. EMS magazine. 2008;37(9):61…
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psnet.ahrq.gov/node/41018/psn-pdf
December 21, 2011 - What stands in the way of technology-mediated patient
safety improvements? A study of facilitators and barriers
to physicians' use of electronic health records.
December 21, 2011
Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of
facilitators and barriers to physician…
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psnet.ahrq.gov/node/46279/psn-pdf
August 02, 2017 - Recognizing the ordinary as extraordinary: insight into
the "way we work" to improve patient safety outcomes.
August 2, 2017
Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve
Patient Safety Outcomes. Am J Crit Care. 2017;26(4):272-277. doi:10.4037/ajcc2017812.
https:…
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psnet.ahrq.gov/node/47230/psn-pdf
August 15, 2018 - Experience feedback committees: a way of implementing
a root cause analysis practice in hospital medical
departments.
August 15, 2018
François P, Lecoanet A, Caporossi A, et al. Experience feedback committees: A way of implementing a
root cause analysis practice in hospital medical departments. PLoS One. 2018;13(7…
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psnet.ahrq.gov/node/43744/psn-pdf
December 03, 2014 - Mobile physician reporting of clinically significant
events—a novel way to improve handoff communication
and supervision of resident on call activities.
December 3, 2014
Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel
way to improve handoff communication…