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psnet.ahrq.gov/node/43409/psn-pdf
February 25, 2015 - Evaluating iatrogenic prescribing: development of an
oncology-focused trigger tool.
February 25, 2015
Hébert G, Netzer F, Ferrua M, et al. Evaluating iatrogenic prescribing: development of an oncology-focused
trigger tool. Eur J Cancer. 2015;51(3):427-35. doi:10.1016/j.ejca.2014.12.002.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/35415/psn-pdf
December 21, 2008 - Acting Locally: Working in Clinical Microsystems CD-
ROM.
December 21, 2008
Oakbrook Terrance, IL: Joint Commission Resources; 2005. ISBN 9780866889865.
https://psnet.ahrq.gov/issue/acting-locally-working-clinical-microsystems-cd-rom
This resource represents a collection of special articles published in the Joint …
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psnet.ahrq.gov/node/45890/psn-pdf
February 15, 2017 - A Framework for Safe, Reliable, and Effective Care.
February 15, 2017
Frankel A, Haraden C, Federico F, Lenoci-Edwards J. Cambridge, MA: Institute for Healthcare
Improvement and Safe & Reliable Healthcare; 2017.
https://psnet.ahrq.gov/issue/framework-safe-reliable-and-effective-care
A systems approach to safety ca…
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psnet.ahrq.gov/node/47145/psn-pdf
July 23, 2018 - The elusive and illusive quest for diagnostic safety
metrics.
July 23, 2018
Schiff G, Ruan EL. The Elusive and Illusive Quest for Diagnostic Safety Metrics. J Gen Intern Med.
2018;33(7):983-985. doi:10.1007/s11606-018-4454-2.
https://psnet.ahrq.gov/issue/elusive-and-illusive-quest-diagnostic-safety-metrics
Measur…
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psnet.ahrq.gov/node/43373/psn-pdf
July 23, 2014 - From harm to hope and purposeful action: what could we
do after Francis?
July 23, 2014
Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do
after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581.
https://psnet.ahrq.gov/issue/harm-hope-and-purpo…
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psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…
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psnet.ahrq.gov/node/36226/psn-pdf
August 30, 2006 - Framework for a High Performance Health System for the
United States.
August 30, 2006
Mongan JJ. New York, NY; The Commonwealth Fund: 2006.
https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states
This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
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psnet.ahrq.gov/node/46043/psn-pdf
April 05, 2017 - High-reliability and the I-PASS communication tool.
April 5, 2017
Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse).
2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5.
https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool
High reliability has y…
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psnet.ahrq.gov/node/39599/psn-pdf
December 27, 2014 - The role of housestaff in implementing medication
reconciliation on admission at an academic medical
center.
December 27, 2014
Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on
admission at an academic medical center. Am J Med Qual. 2011;26(1):39-42.
doi:10.1…
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psnet.ahrq.gov/node/45289/psn-pdf
May 03, 2017 - Measuring harm in health care: optimizing adverse event
review.
May 3, 2017
Walsh KE, Harik P, Mazor KM, et al. Measuring Harm in Health Care: Optimizing Adverse Event Review.
Med Care. 2017;55(4):436-441. doi:10.1097/MLR.0000000000000679.
https://psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-…
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psnet.ahrq.gov/node/46367/psn-pdf
August 30, 2017 - Why are so many women being misdiagnosed?
August 30, 2017
Mickle K. Glamour. August 11, 2017.
https://psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed
Implicit bias and differences in communication style can affect patient care. This magazine article reports
on factors that contribute to misdiagnosis …
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psnet.ahrq.gov/node/44718/psn-pdf
November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient
Safety.
November 25, 2015
Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto;
2015.
https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
The 2004 Canadian Adverse Events Study helpe…
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psnet.ahrq.gov/node/41498/psn-pdf
December 31, 2014 - Standard practices for computerized clinical decision
support in community hospitals: a national survey.
December 31, 2014
Ash JS, McCormack JL, Sittig DF, et al. Standard practices for computerized clinical decision support in
community hospitals: a national survey. J Am Med Inform Assoc. 2012;19(6):980-7. doi:10.…
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psnet.ahrq.gov/node/47647/psn-pdf
January 23, 2019 - Patient Safety: Global Action on Patient Safety.
January 23, 2019
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12,
2018.
https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety
This guidance summarizes the current status of global patient safety,…
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psnet.ahrq.gov/node/45038/psn-pdf
February 18, 2017 - Re-examining high reliability: actively organising for
safety.
February 18, 2017
Sutcliffe K, Paine LA, Pronovost P. Re-examining high reliability: actively organising for safety. BMJ Qual
Saf. 2017;26(3):248-251. doi:10.1136/bmjqs-2015-004698.
https://psnet.ahrq.gov/issue/re-examining-high-reliability-actively-or…
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psnet.ahrq.gov/node/46333/psn-pdf
June 25, 2018 - High reliability leadership: a conceptual framework.
June 25, 2018
Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage.
2017;26(2):237-246. doi:10.1111/1468-5973.12187.
https://psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework
Leadership engag…
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psnet.ahrq.gov/node/37994/psn-pdf
February 08, 2017 - Changes in practice and organisation surrounding blood
transfusion in NHS trusts in England 1995-2005.
February 8, 2017
Taylor CJC, Murphy MF, Lowe D, et al. Changes in practice and organisation surrounding blood
transfusion in NHS trusts in England 1995-2005. Qual Saf Health Care. 2008;17(4):239-43.
doi:10.1136/q…
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psnet.ahrq.gov/node/44998/psn-pdf
April 20, 2016 - High reliability: excellent care every time.
April 20, 2016
Saver C. High reliability: Excellent care every time. OR manager. 2016;32(3):22-6.
https://psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
Achieving high reliability has attracted attention as a goal in health care. This article provides an…
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psnet.ahrq.gov/node/43879/psn-pdf
February 04, 2015 - Complaints and Raising Concerns.
February 4, 2015
Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The
Stationery Office; January 13, 2015. Publication HC 350.
https://psnet.ahrq.gov/issue/complaints-and-raising-concerns
Complaints are a proactive way to monitor and address rec…
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psnet.ahrq.gov/node/33958/psn-pdf
December 18, 2008 - A review of the literature examining linkages between
organizational factors, medical errors, and patient safety.
December 18, 2008
Hoff T, Jameson L, Hannan E, et al. A review of the literature examining linkages between organizational
factors, medical errors, and patient safety. Med Care Res Rev. 2004;61(1):3-37.…