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psnet.ahrq.gov/node/836822/psn-pdf
March 30, 2022 - Leveraging a safety event management system to
improve organizational learning and safety culture.
March 30, 2022
Dawson R, Saulnier T, Campbell A, et al. Leveraging a safety event management system to improve
organizational learning and safety culture. Hosp Pediatr. 2022;12(4):407-417. doi:10.1542/hpeds.2021-
006…
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psnet.ahrq.gov/node/73563/psn-pdf
August 04, 2021 - Understanding complaints made about surgical
departments in a UK district general hospital.
August 4, 2021
Claydon O, Keeler B, Khanna A. Understanding complaints made about surgical departments in a UK
district general hospital. Int J Qual Health Care. 2021;33(3). doi:10.1093/intqhc/mzab095.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/853619/psn-pdf
September 20, 2023 - Defining speaking up in the healthcare system: a
systematic review.
September 20, 2023
Kane J, Munn L, Kane SF, et al. Defining speaking up in the healthcare system: a systematic review. J Gen
Intern Med. 2023;38(15):3406-3413. doi:10.1007/s11606-023-08322-0.
https://psnet.ahrq.gov/issue/defining-speaking-healthca…
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psnet.ahrq.gov/node/73413/psn-pdf
June 23, 2021 - Interventions to reduce pediatric prescribing errors in
professional healthcare settings: a systematic review of
the last decade.
June 23, 2021
Koeck JA, Young NJ, Kontny U, et al. Interventions to Reduce Pediatric Prescribing Errors in Professional
Healthcare Settings: A Systematic Review of the Last Decade. Pedi…
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psnet.ahrq.gov/node/72657/psn-pdf
January 20, 2021 - Establishing a multi-institutional quality and patient
safety consortium: collaboration across affiliates in a
community-based medical school.
January 20, 2021
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium:
collaboration across affiliates in a commun…
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psnet.ahrq.gov/node/838252/psn-pdf
October 05, 2022 - A longitudinal study of a multifaceted intervention to
reduce newborn falls while preserving rooming-in on a
mother-baby unit.
October 5, 2022
Whatley C, Schlogl J, Whalen BL, et al. A longitudinal study of a multifaceted intervention to reduce
newborn falls while preserving rooming-in on a mother-baby unit. Jt Co…
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psnet.ahrq.gov/node/46384/psn-pdf
November 14, 2018 - Peggy Lillis Foundation.
November 14, 2018
266 12th Street #6, Brooklyn, NY 11215.
https://psnet.ahrq.gov/issue/peggy-lillis-foundation
Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots
foundation employs educational, policy, and advocacy strategies aimed at red…
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psnet.ahrq.gov/node/35383/psn-pdf
January 02, 2017 - North Mississippi Medical Center: a focus on quality,
safety, and financial critical success factors.
January 2, 2017
Murphree J, Englert J, Koch K, et al. North Mississippi Medical Center: a focus on quality, safety, and
financial critical success factors. Jt Comm J Qual Patient Saf. 2005;31(10):545-53.
https://p…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/34731/psn-pdf
July 08, 2016 - Crossing the Quality Chasm: A New Health System for the
21st Century.
July 8, 2016
Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National
Academies Press; 2001. ISBN: 9780309072809.
https://psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century
Following…
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psnet.ahrq.gov/node/867443/psn-pdf
January 08, 2025 - Investigating the impact of a pharmacist intervention on
inappropriate prescribing practices at hospital admission
and discharge in older patients: a secondary outcome
analysis from a randomized controlled trial.
January 8, 2025
Garcia BH, Omma KK, Småbrekke L, et al. Investigating the impact of a pharmacist inter…
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psnet.ahrq.gov/node/866643/psn-pdf
September 04, 2024 - Three scans are better than two for follow-up: an
automatic method for finding missed and misidentified
lesions in cross-sectional follow-up of oncology patients.
September 4, 2024
Joskowicz L, Di Veroli B, Lederman R, et al. Three scans are better than two for follow-up: an automatic
method for finding missed and…
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psnet.ahrq.gov/node/867082/psn-pdf
November 06, 2024 - Learning in radiation oncology: 12-month experience with
a new incident learning system.
November 6, 2024
Crouch K, Adamson L, Beldham?Collins R, et al. Learning in radiation oncology: 12?month experience with
a new incident learning system. J Med Radiat Sci. 2024;Epub Sep 15. doi:10.1002/jmrs.823.
https://psnet.a…
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psnet.ahrq.gov/node/867087/psn-pdf
January 01, 2025 - The impact of surgical complications on obstetricians'
and gynecologists' wellbeing and coping mechanisms as
second victims.
November 6, 2024
Collings R, Potter C, Gebski V, et al. The impact of surgical complications on obstetricians’ and
gynecologists’ well-being and coping mechanisms as second victims. Am J Obs…
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psnet.ahrq.gov/node/866584/psn-pdf
August 28, 2024 - Raising the barcode: improving medication safety
behaviours through a behavioural science-informed
feedback intervention. A quality improvement project and
difference-in-difference analysis.
August 28, 2024
Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving medication safety behaviours
throu…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/43465/psn-pdf
February 18, 2015 - Hospital Readmissions Reduction Program: implications
for pharmacy.
February 18, 2015
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for
pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
https://psnet.ahrq.gov/issue/hospital-readmissions-redu…
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psnet.ahrq.gov/node/45046/psn-pdf
July 05, 2016 - Diagnosing sepsis is subjective and highly variable: a
survey of intensivists using case vignettes.
July 5, 2016
Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: a survey of
intensivists using case vignettes. Crit Care. 2016;20:89. doi:10.1186/s13054-016-1266-9.
https://psne…
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psnet.ahrq.gov/node/34800/psn-pdf
December 23, 2008 - A classification system for incidents and accidents in the
health-care system.
December 23, 2008
Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care
system. J Qual Clin Pract. 1998;18(3):199-211.
https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…
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psnet.ahrq.gov/node/33932/psn-pdf
May 27, 2011 - Preventable anesthesia mishaps: a study of human
factors.
May 27, 2011
Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors.
Anesthesiology. 1978;49(6):399-406.
https://psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
This study reports on the ret…