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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions
Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD
| November 16, 2022
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - that involve clinician decision-making and procedural competency—be addressed in equally innovative ways
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - SS : Well, I think that infection prevention in many ways is a paradigm for patient safety, at least
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - Measurement of PFE
There are currently a number of ways that entities can assess the level of PFE at
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
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Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - Xiao and colleagues recently showed that highly skilled trauma teams communicated in a variety of ways … —There are many types of communication failures and many ways to classify them.
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - The challenge is to develop efficient, useful ways to provide clinicians with corroborative knowledge
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - initially postponed, as the pandemic has continued, providers have been forced to explore innovative ways … There are so many ways you could integrate sensors to monitor changes in a patient’s condition.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - The NPSGs offer ways to develop proactive system-level processes of care to promote patient safety instead
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - One this is done, “failure modes”, i.e., ways in which a process or product could potentially fail or
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - for settings outside the hospital, improving the quality of safety reporting systems, and developing ways
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - In many ways, this level of communication and questioning is admirable and might well reflect a
safe
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout
Citation Text:
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - pain, but it's also to be mindful of the potential for some of your medicines to harm you—sometimes in ways
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - SPOTLIGHT CASE
Delay in Initiating Antibiotics Results in Fatal Error
Citation Text:
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Promotion issued the National Action Plan for Adverse Drug Event Prevention in 2014, which identified ways
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Bar-coding or impregnating sponges with detectable sensors would be new ways to improve an old practice
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psnet.ahrq.gov/perspective/safety-culture-ems
May 26, 2021 - Safety Culture in EMS
May 26, 2021
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Citation Text:
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US…
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Patients and Families provides resources for providers to partner with patients to improve engagement in ways