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psnet.ahrq.gov/issue/events-inspired-change-importance-sharing-what-happened-stop-it-happening-again
August 07, 2024 - Commentary
Events that inspired change: the importance of sharing what happened to stop it from happening again.
Citation Text:
Myers E, Allen C. Events that inspired change: the importance of sharing what happened to stop it from happening again. Patient Saf. 2023;5(1):62-63. doi:10.339…
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psnet.ahrq.gov/issue/exploring-barriers-learning-crisis-organizational-learning-and-crisis
January 08, 2025 - Review
Exploring the barriers to learning from crisis: organizational learning and crisis.
Citation Text:
Smith D, Elliott D. Exploring the Barriers to Learning from Crisis. Manag Learn. 2007;38(5):519-538. doi:10.1177/1350507607083205.
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psnet.ahrq.gov/issue/finding-and-fixing-diagnosis-errors-can-triggers-help
January 31, 2024 - Commentary
Finding and fixing diagnosis errors: can triggers help?
Citation Text:
Schiff GD. Finding and fixing diagnosis errors: can triggers help? BMJ Qual Saf. 2011;21(2):89-92. doi:10.1136/bmjqs-2011-000590.
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psnet.ahrq.gov/issue/improving-diagnostic-decision-support-through-deliberate-reflection-proposal
September 23, 2020 - Commentary
Improving diagnostic decision support through deliberate reflection: a proposal.
Citation Text:
Schmidt HG, Mamede S. Improving diagnostic decision support through deliberate reflection: a proposal. Diagnosis (Berl). 2023;10(1):38-42. doi:10.1515/dx-2022-0062.
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psnet.ahrq.gov/issue/economics-medication-safety-improving-medication-safety-through-collective-real-time-learning
October 07, 2020 - Book/Report
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning.
Citation Text:
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. de Bienassis K, Esmail L, Lopert R, Klazinga N for the O…
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psnet.ahrq.gov/issue/pursuit-endpoint-diagnoses-cognitive-forcing-strategy-avoid-premature-diagnostic-closure
November 02, 2022 - Commentary
Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.
Citation Text:
Kaplan HM, Birnbaum JF, Kulkarni PA. Pursuit of “endpoint diagnoses” as a cognitive forcing strategy to avoid premature diagnostic closure. Diagnosis (Berl). 2…
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psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners
October 19, 2022 - Review
Diagnostic reasoning and cognitive biases of nurse practitioners.
Citation Text:
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ. 2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
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psnet.ahrq.gov/issue/delineation-risk-through-exploration-culture-safety-community-home-health
December 04, 2016 - Study
Delineation of risk through the exploration of a culture of safety in community home health.
Citation Text:
Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:…
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psnet.ahrq.gov/issue/patient-safety-attitudes-paediatric-trainee-physicians
December 01, 2010 - Study
Patient safety attitudes of paediatric trainee physicians.
Citation Text:
Parry G, Horowitz L, Goldmann D. Patient safety attitudes of paediatric trainee physicians. Qual Saf Health Care. 2009;18(6):462-6. doi:10.1136/qshc.2006.020230.
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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psnet.ahrq.gov/issue/implementation-safety-huddle
November 03, 2021 - Commentary
Implementation of the safety huddle.
Citation Text:
Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80-82.
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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psnet.ahrq.gov/issue/minimizing-inappropriate-medications-older-populations-ten-step-conceptual-framework
June 23, 2021 - Commentary
Minimizing inappropriate medications in older populations: a ten-step conceptual framework.
Citation Text:
Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1…
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psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs
November 12, 2014 - Commentary
I-PASS, a mnemonic to standardize verbal handoffs.
Citation Text:
Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-4. doi:10.1542/peds.2011-2966.
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psnet.ahrq.gov/issue/prevention-fall-related-injuries-long-term-care-randomized-controlled-trial-staff-education
February 17, 2011 - Study
Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education.
Citation Text:
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. Arch Intern Med. 20…
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psnet.ahrq.gov/issue/email-communicating-results-diagnostic-medical-investigations-patients
December 14, 2016 - Review
Email for communicating results of diagnostic medical investigations to patients.
Citation Text:
Meyer B, Atherton H, Sawmynaden P, et al. Email for communicating results of diagnostic medical investigations to patients. Cochrane Database of Systematic Reviews. 2012. doi:10.1002…
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psnet.ahrq.gov/issue/northeastern-university-hospital-surge-capacity-planning-model-bed-ventilator-and-ppe-1-30
December 24, 2008 - Tools/Toolkit
Northeastern University Hospital Surge Capacity Planning Model: Bed, Ventilator, and PPE 1-30 Day Demand.
Citation Text:
Northeastern University Hospital Surge Capacity Planning Model: Bed, Ventilator, and PPE 1-30 Day Demand. Rockville, MD; Agency for Healthcare Research a…
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psnet.ahrq.gov/issue/measure-dx-implementing-pathways-discover-and-learn-diagnostic-errors
August 25, 2021 - Commentary
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
Citation Text:
Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068.…
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psnet.ahrq.gov/issue/taking-challenge-improve-name-and-role-recognition-operating-room
July 12, 2023 - Review
Taking up the challenge to improve name and role recognition in the operating room.
Citation Text:
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.00000000000011…
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psnet.ahrq.gov/issue/mitigating-hazards-through-continuing-design-birth-and-evolution-pediatric-intensive-care
April 06, 2011 - Commentary
Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit.
Citation Text:
Madsen P, Desai V, Roberts K, et al. Mitigating Hazards Through Continuing Design: The Birth and Evolution of a Pediatric Intensive Care Unit. Organizati…