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psnet.ahrq.gov/node/47645/psn-pdf
April 17, 2019 - When a nurse is prosecuted for a fatal medical mistake,
does it make medicine safer?
April 17, 2019
Gordon M. Health Shots. National Public Radio. April 10, 2019.
https://psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer
Punitive responses to medical errors persist despit…
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psnet.ahrq.gov/node/41022/psn-pdf
December 21, 2011 - Key performance outcomes of patient safety curricula:
root cause analysis, failure mode and effects analysis,
and structured communications skills.
December 21, 2011
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and
effects analysis, and structured communicatio…
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psnet.ahrq.gov/node/44408/psn-pdf
April 12, 2017 - Enhancing Surgical Performance: A Primer in Non-
technical Skills.
April 12, 2017
Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322.
https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills
Non-technical skill development is gaining attention as a way …
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psnet.ahrq.gov/node/41306/psn-pdf
May 04, 2012 - Identifying nontechnical skills associated with safety in
the emergency department: a scoping review of the
literature.
May 4, 2012
Flowerdew L, Brown R, Vincent CA, et al. Identifying nontechnical skills associated with safety in the
emergency department: a scoping review of the literature. Ann Emerg Med. 2012;59…
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psnet.ahrq.gov/node/41648/psn-pdf
September 30, 2012 - Using an objective structured clinical examination to test
adherence to Joint Commission National Patient Safety
Goal–associated behaviors.
September 30, 2012
Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test
adherence to Joint Commission National Patient Safety Goal-…
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psnet.ahrq.gov/node/47389/psn-pdf
November 02, 2018 - What 'just culture' doesn't understand about just
punishment.
November 2, 2018
Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics.
2018;44(11):739-742. doi:10.1136/medethics-2018-104911.
https://psnet.ahrq.gov/issue/what-just-culture-doesnt-understand-about-just-punishment
T…
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psnet.ahrq.gov/node/46023/psn-pdf
May 03, 2017 - Patient safety and leadership: do you walk the walk?
May 3, 2017
Jarrett MP. Patient Safety and Leadership: Do You Walk the Walk? J Healthc Manag. 2017;62(2):88-92.
doi:10.1097/JHM-D-17-00005.
https://psnet.ahrq.gov/issue/patient-safety-and-leadership-do-you-walk-walk
Hospital leaders are increasingly encouraged t…
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psnet.ahrq.gov/node/34750/psn-pdf
May 21, 2019 - The Basics of FMEA. 2nd ed.
May 21, 2019
McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773.
https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition
The authors provide a handbook that serves as the core tool for understanding and implementing the
failure mode and effect analy…
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psnet.ahrq.gov/node/43820/psn-pdf
February 18, 2015 - Care of the clinician after an adverse event.
February 18, 2015
Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth. 2014;24(1):54-63.
doi:10.1016/j.ijoa.2014.10.001.
https://psnet.ahrq.gov/issue/care-clinician-after-adverse-event
Spotlighting the emotional impact adverse events …
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psnet.ahrq.gov/node/46213/psn-pdf
June 28, 2017 - The second victim: a review.
June 28, 2017
Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol.
2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002.
https://psnet.ahrq.gov/issue/second-victim-review
Maternity care is a high-risk environment. This review discusses second vic…
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psnet.ahrq.gov/node/60065/psn-pdf
March 18, 2020 - Safety in Numbers: Hospital Performance on Leapfrog’s
Surgical Volume Standard Based on Results of the 2019
Leapfrog Hospital Survey.
March 18, 2020
Washington DC: Leapfrog Group; 2020.
https://psnet.ahrq.gov/issue/safety-numbers-hospital-performance-leapfrogs-surgical-volume-standard-
based-results-2019
Surgica…
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psnet.ahrq.gov/node/47081/psn-pdf
September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing
digital tools for diagnosis.
September 2, 2018
Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital
tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009.
https://psnet.ahrq.gov/issue/b…
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psnet.ahrq.gov/node/43515/psn-pdf
July 03, 2016 - Targeting improvements in patient safety at a large
academic center: an institutional handoff curriculum for
graduate medical education.
July 3, 2016
Allen S, Caton C, Cluver J, et al. Targeting improvements in patient safety at a large academic center: an
institutional handoff curriculum for graduate medical educ…
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psnet.ahrq.gov/node/836789/psn-pdf
March 23, 2022 - COVID-19 Focused Inspection Initiative in Healthcare.
March 23, 2022
Occupational Safety and Health Administration. March 2, 2022.
https://psnet.ahrq.gov/issue/covid-19-focused-inspection-initiative-healthcare
The impact of nursing home inspections to ensure the quality and safety of the service environment is…
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psnet.ahrq.gov/node/46208/psn-pdf
July 12, 2017 - Improving patient safety by practicing in a just culture.
July 12, 2017
Duffy W. Improving Patient Safety by Practicing in a Just Culture. AORN J. 2017;106(1):66-68.
doi:10.1016/j.aorn.2017.05.005.
https://psnet.ahrq.gov/issue/improving-patient-safety-practicing-just-culture
The importance of just culture is widel…
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psnet.ahrq.gov/node/862999/psn-pdf
February 21, 2024 - Health tech hazards: at-home medical devices, AI
governance on ECRI's new list.
February 21, 2024
Miliard M. Healthcare IT News. February 1, 2024.
https://psnet.ahrq.gov/issue/health-tech-hazards-home-medical-devices-ai-governance-ecris-new-list
Technologies provide improvements and introduce unique problems to ca…
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psnet.ahrq.gov/node/44300/psn-pdf
July 29, 2015 - Learning From Serious Failings in Care: Main Report.
July 29, 2015
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges
and Faculties in Scotland; May 2015.
https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
Substantive reports of failures have t…
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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