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psnet.ahrq.gov/node/43051/psn-pdf
May 29, 2014 - A just culture after Mid Staffordshire.
May 29, 2014
Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8.
doi:10.1136/bmjqs-2013-002483.
https://psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire
In the context of public reactions to the Francis report, this commentar…
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psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-report-2017
November 27, 2018 - Book/Report
America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2017.
Citation Text:
America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2017. Oakbrook Terrace; IL: Joint Commission; 2017.
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…
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2012
November 02, 2012 - Book/Report
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.
Citation Text:
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Oakbrook Terrace, IL: The Joint Commission; September 2012.
C…
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psnet.ahrq.gov/issue/professionalism-lapses-and-adverse-childhood-experiences-reflections-island-last-resort
October 14, 2015 - Commentary
Professionalism lapses and adverse childhood experiences: reflections from the island of last resort.
Citation Text:
Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/A…
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psnet.ahrq.gov/issue/missed-medication-doses-hospitalised-patients-descriptive-account-quality-improvement
October 13, 2018 - Study
Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis.
Citation Text:
Coleman JJ, Hodson J, Brooks HL, et al. Missed medication doses in hospitalised patients: a descriptive account of quality improvement me…
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psnet.ahrq.gov/issue/pediatric-patient-safety-events-during-hospitalization-approaches-accounting-institution
December 23, 2012 - Study
Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects.
Citation Text:
Slonim A, Marcin JP, Turenne W, et al. Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects. He…
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psnet.ahrq.gov/node/845298/psn-pdf
March 01, 2023 - National statutory reporting: not even ticking the boxes?
The quality of 'Learning from Deaths' reporting in quality
accounts within the NHS in England 2017-2020.
March 1, 2023
Brummell Z, Braun D, Hussein Z, et al. National statutory reporting: not even ticking the boxes? The quality
of ‘Learning from Deaths’ rep…
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psnet.ahrq.gov/node/40000/psn-pdf
November 10, 2017 - Behind Human Error, Second Edition.
November 10, 2017
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
https://psnet.ahrq.gov/issue/behind-human-error-second-edition
"Human error," the authors of this book argue, is an inherently misleading term. Drawing on the field …
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psnet.ahrq.gov/node/44132/psn-pdf
May 13, 2015 - Adverse outcomes: why bad things happen to good
people.
May 13, 2015
Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol.
2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064.
https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people
This commentary…
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psnet.ahrq.gov/issue/tracking-progress-patient-safety-elusive-target
March 13, 2013 - Commentary
Tracking progress in patient safety: an elusive target.
Citation Text:
Pronovost P, Miller MR, Wachter R. Tracking progress in patient safety: an elusive target. JAMA. 2006;296(6):696-9.
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psnet.ahrq.gov/issue/shepherding-change-how-market-healthcare-providers-and-public-policy-can-deliver-quality-care
July 20, 2022 - Commentary
Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.
Citation Text:
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st…
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psnet.ahrq.gov/node/46006/psn-pdf
May 03, 2017 - Creating a Pediatric Joint Council to promote patient
safety and quality, governance, and accountability across
Johns Hopkins Medicine.
May 3, 2017
Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety
and Quality, Governance, and Accountability Across Johns Hopkins…
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psnet.ahrq.gov/node/45028/psn-pdf
May 25, 2016 - 'Just culture': improving safety by achieving substantive,
procedural and restorative justice.
May 25, 2016
Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and
restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.
https://psnet.ahrq.gov/issue/just-cultu…
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psnet.ahrq.gov/node/45146/psn-pdf
July 18, 2016 - Driving surgical quality using operative video.
July 18, 2016
O'Mahoney PRA, Yeo HL, Lange MM, et al. Driving Surgical Quality Using Operative Video. Surg Innov.
2016;23(4):337-40. doi:10.1177/1553350616643616.
https://psnet.ahrq.gov/issue/driving-surgical-quality-using-operative-video
Although using video documen…
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psnet.ahrq.gov/issue/outcomes-michigan-medicines-integrated-patient-safety-and-communication-and-resolution
April 24, 2018 - Study
Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022.
Citation Text:
Burney RE, Mckeown ES, Zhang Y, et al. Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022. J Pati…
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psnet.ahrq.gov/issue/requirements-implementing-just-culture-within-healthcare-organisations-integrative-review
October 31, 2014 - Review
Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.
Citation Text:
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)…
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psnet.ahrq.gov/issue/infections-and-interaction-rituals-organisation-clinician-accounts-speaking-or-remaining
November 03, 2015 - Study
Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety.
Citation Text:
Szymczak JE. Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining…
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psnet.ahrq.gov/node/41741/psn-pdf
October 10, 2012 - Improving America's Hospitals—The Joint Commission's
Annual Report on Quality and Safety.
October 10, 2012
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety
The Joint Commission's annual report summarizes hospital …
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psnet.ahrq.gov/node/39959/psn-pdf
December 21, 2014 - Hospital process compliance and surgical outcomes in
Medicare beneficiaries.
December 21, 2014
Nicholas LH, Osborne NH, Birkmeyer JD, et al. Hospital process compliance and surgical outcomes in
medicare beneficiaries. Arch Surg. 2010;145(10):999-1004. doi:10.1001/archsurg.2010.191.
https://psnet.ahrq.gov/issue/hos…
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psnet.ahrq.gov/issue/serious-misdiagnosis-related-harms-malpractice-claims-big-three-vascular-events-infections
July 28, 2023 - Study
Emerging Classic
Serious misdiagnosis-related harms in malpractice claims: the "Big Three": vascular events, infections, and cancers.
Citation Text:
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: T…