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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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psnet.ahrq.gov/issue/video-games-can-help-cut-surgical-errors
January 23, 2008 - Newspaper/Magazine Article
Video games can help cut surgical errors.
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Video games can help cut surgical errors. Baertlein L.
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psnet.ahrq.gov/issue/health-care-industry-agrees-patient-safety-rules
August 17, 2016 - Newspaper/Magazine Article
Health-care industry agrees on patient safety rules.
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Health-care industry agrees on patient safety rules. Landro L.
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It
Jerry Gurwitz, MD | August 1, 2012
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Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix I…
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
Also Read an Essay
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In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - Getting Into Patient Safety: A Personal Story
Jeffrey B. Cooper, PhD | August 1, 2006
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Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/issue/scoping-review-methodological-approaches-used-retrospective-chart-reviews-validate-adverse
April 29, 2020 - Review
A scoping review of the methodological approaches used in retrospective chart reviews to validate adverse event rates in administrative data.
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Connolly A, Kirwan M, Matthews A. A scoping review of the methodological approaches used in retrospective chart reviews to v…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
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Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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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
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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/surgical-data-recording-technology-solution-address-medical-errors
June 22, 2022 - Commentary
Surgical data recording technology: a solution to address medical errors?
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Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433. doi:10.1097/sla.0000000000003510.
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psnet.ahrq.gov/issue/vital-signs-core-metrics-health-and-health-care-progress
November 24, 2021 - Book/Report
Vital Signs: Core Metrics for Health and Health Care Progress.
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Vital Signs: Core Metrics for Health and Health Care Progress. Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washingto…
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psnet.ahrq.gov/issue/how-talk-about-patient-safety
June 24, 2019 - Book/Report
How to Talk About Patient Safety.
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How to Talk About Patient Safety. Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
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psnet.ahrq.gov/issue/medication-safety-emergency-medical-services-approaching-evidence-based-method-verification
September 28, 2022 - Study
Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors.
Citation Text:
Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther …
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psnet.ahrq.gov/issue/learning-how-learn-compliance-patient-safety-alerts-nhs
September 01, 2021 - Government Resource
Learning how to learn: compliance with patient safety alerts in the NHS.
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Learning how to learn: compliance with patient safety alerts in the NHS. Donaldson L. Chapter in: On the State of Public Health: Annual Report of the Chief Medical Officer. L…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - resilience engineering focuses on learning proactively about how things usually go well and developing ways
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - In this process, a step-by-step approach to the workflow should be simulated and assessed for ways in
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psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
September 12, 2018 - Book/Report
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
Citation Text:
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Nat…
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - Newspaper/Magazine Article
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.
Citation Text:
Government and industry fail to protect the public when they suggest "carefully following instructions" i…
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psnet.ahrq.gov/issue/thematic-reviews-patient-safety-incidents-tool-systems-thinking-quality-improvement-report
January 15, 2020 - Commentary
Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.
Citation Text:
Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Qual. 2023;12(2):e002020. doi…