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psnet.ahrq.gov/node/37858/psn-pdf
June 25, 2008 - Measuring team performance in healthcare: review of
research and implications for patient safety.
June 25, 2008
Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and
implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.1016/j.jcrc.2007.12.005.
https://psnet.…
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psnet.ahrq.gov/node/36041/psn-pdf
June 21, 2006 - Intraoperative adverse events and related postoperative
complications in spine surgery: implications for
enhancing patient safety founded on evidence-based
protocols.
June 21, 2006
Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG.
https://psnet.ahrq.gov/issue/intraoperative-adverse-…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/38701/psn-pdf
June 28, 2011 - Selection of indicators for continuous monitoring of
patient safety: recommendations of the project 'safety
improvement for patients in Europe.'
June 28, 2011
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety:
recommendations of the project 'safety improvement f…
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psnet.ahrq.gov/node/60563/psn-pdf
June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID
testing In unexplained deaths.
June 3, 2020
Andrews M. Kaiser News Network. May 19, 2020.
https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths
Post-mortem examination is an important tool for determining if misdiagnos…
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psnet.ahrq.gov/node/866357/psn-pdf
July 24, 2024 - People’s Experiences of Diagnosis.
July 24, 2024
People’s Experiences Of Diagnosis. London, England: National Voices; June 2024.
https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis
The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report
explores the diagnosti…
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psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
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psnet.ahrq.gov/node/73451/psn-pdf
June 30, 2021 - National Patient Safety Syllabus.
June 30, 2021
Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021.
https://psnet.ahrq.gov/issue/national-patient-safety-syllabus
Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a
challenge. This st…
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psnet.ahrq.gov/node/34719/psn-pdf
December 23, 2008 - Learning from samples of one or fewer.
December 23, 2008
March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-
472.)
https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer
Organizations learn from experience. However, learning from rare events is challenging becau…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…
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psnet.ahrq.gov/node/37086/psn-pdf
October 03, 2011 - Failure mode and effects analysis: a useful tool for risk
identification and injury prevention.
October 3, 2011
Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…
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psnet.ahrq.gov/node/36622/psn-pdf
January 14, 2011 - Measuring errors in surgical pathology in real-life
practice: defining what does and does not matter.
January 14, 2011
Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does
and does not matter. Am J Clin Pathol. 2007;127(1):144-52.
https://psnet.ahrq.gov/issue/measu…
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psnet.ahrq.gov/node/34887/psn-pdf
February 26, 2009 - Has the Leapfrog Group had an impact on the health care
market?
February 26, 2009
Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market?
Health Aff (Millwood). 2005;24(1):228-33.
https://psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market
The Le…
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psnet.ahrq.gov/node/43375/psn-pdf
July 23, 2014 - Managing risk at the point-of-care: preventing errors.
July 23, 2014
Njoroge S; Nichols JH.
https://psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors
Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action
and laboratory staff performing the analys…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS | February 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baron RB, Vidyarthi A. The Role of Gra…
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - In Conversation with…Thomas J. Nasca, MD
February 1, 2010
Also Read an Essay
Citation Text:
In Conversation with…Thomas J. Nasca, MD. 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/issue/readiness-report-medical-treatment-errors-effects-safety-procedures-safety-information-and
July 11, 2007 - Study
Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.
Citation Text:
Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety procedures, safety information, and prior…
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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