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  1. 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…
  2. 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. Copy Citation Format: DOI Google Sc…
  3. 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. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML…
  4. 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. Copy Citation …
  5. 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…
  6. 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…
  7. 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. Copy Citation Format: DOI Google Scholar P…
  8. 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:…
  9. 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. Copy Citation Format: DOI Goog…
  10. 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. Copy Citation Format: …
  11. 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. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  12. 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…
  13. 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…
  14. 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. Copy Citation Format: DOI Google Scholar…
  15. 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…
  16. 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…
  17. 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…
  18. 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.…
  19. 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…
  20. 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…

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