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psnet.ahrq.gov/issue/sample-sample-carryover-source-analytical-laboratory-error-and-its-relevance-integrated
January 12, 2022 - Study
Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.
Citation Text:
Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its relevance to integra…
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psnet.ahrq.gov/issue/organizational-framework-reduce-professional-burnout-and-bring-back-joy-practice
February 03, 2016 - Commentary
An organizational framework to reduce professional burnout and bring back joy in practice.
Citation Text:
Swensen S, Shanafelt TD. An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. Jt Comm J Qual Patient Saf. 2017;43(6):308-313. doi:10.…
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psnet.ahrq.gov/issue/getting-havarti-moving-toward-patient-safety-obstetrics
October 19, 2022 - Commentary
Getting to havarti: moving toward patient safety in obstetrics.
Citation Text:
Veltman LL. Getting to havarti: moving toward patient safety in obstetrics. Obstet Gynecol. 2007;110(5):1146-1150.
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psnet.ahrq.gov/issue/systemic-methodology-risk-management-healthcare-sector
December 23, 2020 - Commentary
A systemic methodology for risk management in healthcare sector.
Citation Text:
Cagliano AC, Grimaldi S, Rafele C. A systemic methodology for risk management in healthcare sector. Saf Sci. 2011;49(5). doi:10.1016/j.ssci.2011.01.006.
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psnet.ahrq.gov/issue/embedding-quality-improvement-and-patient-safety-ucla-value-analysis-experience
October 02, 2019 - Commentary
Embedding quality improvement and patient safety - the UCLA value analysis experience.
Citation Text:
Gambone JC, Broder MS. Embedding quality improvement and patient safety: the UCLA value analysis experience. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):581-92.
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psnet.ahrq.gov/node/42391/psn-pdf
June 26, 2013 - Patient Notification Toolkit.
June 26, 2013
Centers for Disease Control and Prevention; CDC.
https://psnet.ahrq.gov/issue/patient-notification-toolkit
This toolkit provides guidance and resources to help organizations inform patients about infection control
lapses.
https://psnet.ahrq.gov/issue/patient-notificatio…
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psnet.ahrq.gov/node/36357/psn-pdf
December 19, 2009 - Error reporting in organizations.
December 19, 2009
Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030.
https://psnet.ahrq.gov/issue/error-reporting-organizations
The authors provide a framework for individual error reporting behavior that follows three phases: error
detection, situation assessment, and choic…
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psnet.ahrq.gov/node/35765/psn-pdf
September 14, 2008 - Manchester Patient Safety Framework (MaPSaF).
September 14, 2008
Manchester, UK: University of Manchester; 2006.
https://psnet.ahrq.gov/issue/manchester-patient-safety-framework-mapsaf
This tool was developed to help National Health Service organizations assess their progress in
implementing and sustaining a safet…
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psnet.ahrq.gov/node/38320/psn-pdf
July 28, 2013 - State of Healthcare 2008.
July 28, 2013
Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN:
9780102958362.
https://psnet.ahrq.gov/issue/state-healthcare-2008
This report assesses care in the United Kingdom, provides data on a variety of issues related to safety, and
…
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psnet.ahrq.gov/node/36336/psn-pdf
October 26, 2010 - Interprofessional Approaches to Patient Safety.
October 26, 2010
J Interprof Care. 2006;20(5):461-563.
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
This issue includes articles that explore successful multidisciplinary efforts to improve patient safety,
including medication risk assessm…
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psnet.ahrq.gov/node/36534/psn-pdf
March 09, 2009 - Standardizing hand-off processes.
March 9, 2009
Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61.
https://psnet.ahrq.gov/issue/standardizing-hand-processes
The author suggests ways to improve hand-off communications and provides an assessment form to assist
staff in detecting weaknesses in…
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psnet.ahrq.gov/node/38367/psn-pdf
May 24, 2015 - Pathways for Patient Safety.
May 24, 2015
Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group
Management Association; 2009.
https://psnet.ahrq.gov/issue/pathways-patient-safety
This trio of modules provides ambulatory medical practices with tools to develop te…
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psnet.ahrq.gov/node/33959/psn-pdf
January 17, 2012 - Healthcare Failure Mode and Effect Analysis.
January 17, 2012
National Center for Patient Safety.
https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis
(HFMEA), the steps of the HFMEA process, a…
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psnet.ahrq.gov/node/42701/psn-pdf
June 27, 2018 - Improving reliability with root cause analysis.
June 27, 2018
Latino RJ
https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
This article relates how root cause analysis, typically used after an adverse event, can be utilized as a
proactive risk assessment tool to enhance reliability.
https://ps…
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psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - appreciate the consequences of ICU delirium, research has begun to answer key questions about how it can be assessed
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psnet.ahrq.gov/node/37085/psn-pdf
July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and
Technology.
July 15, 2013
Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258.
https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology
This guide provides comprehensive tools for assessment, training, and imple…
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psnet.ahrq.gov/node/36271/psn-pdf
September 20, 2006 - Safe Foundations: Junior Doctors and Patient Safety.
September 20, 2006
National Patient Safety Agency.
https://psnet.ahrq.gov/issue/safe-foundations-junior-doctors-and-patient-safety
This Web site has educational modules for doctors-in-training and provides slides, trainer's notes, and
relevant case studies on hu…
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psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
December 12, 2014 - June 22, 2022
Factors associated with missed nursing care and nurse-assessed quality
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed