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psnet.ahrq.gov/node/74701/psn-pdf
January 26, 2022 - Non-conveyance of older adult patients and association
with subsequent clinical and adverse events after initial
assessment by ambulance clinicians: a cohort analysis.
January 26, 2022
Lederman J, Lindström V, Elmqvist C, et al. Non-conveyance of older adult patients and association with
subsequent clinical and ad…
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psnet.ahrq.gov/node/42932/psn-pdf
December 30, 2014 - SBAR improves communication and safety climate and
decreases incident reports due to communication errors
in an anaesthetic clinic: a prospective intervention study.
December 30, 2014
Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and
decreases incident reports due to com…
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psnet.ahrq.gov/node/45973/psn-pdf
March 29, 2017 - Clinical perspective: creating an effective practice peer
review process—a primer.
March 29, 2017
Gandhi M, Louis FS, Wilson SH, et al. Clinical perspective: creating an effective practice peer review
process-a primer. Am J Obstet Gynecol. 2017;216(3):244-249. doi:10.1016/j.ajog.2016.11.1035.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45576/psn-pdf
July 02, 2017 - Peer feedback, learning, and improvement: answering the
call of the Institute of Medicine report on diagnostic error.
July 2, 2017
Larson DB, Donnelly LF, Podberesky DJ, et al. Peer Feedback, Learning, and Improvement: Answering the
Call of the Institute of Medicine Report on Diagnostic Error. Radiology. 2017;283(1…
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psnet.ahrq.gov/node/837764/psn-pdf
August 03, 2022 - Disparities in adverse event reporting for hospitalized
children.
August 3, 2022
Halvorson EE, Thurtle DP, Easter A, et al. Disparities in adverse event reporting for hospitalized children. J
Patient Saf. 2022;18(6):e928-e933. doi:10.1097/pts.0000000000001049.
https://psnet.ahrq.gov/issue/disparities-adverse-event…
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psnet.ahrq.gov/issue/importance-preparation-doctors-handovers-acute-medical-assessment-unit-hierarchical-task
March 02, 2011 - Study
The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.
Citation Text:
Raduma-Tomàs MA, Flin R, Yule S, et al. The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical …
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psnet.ahrq.gov/issue/enotss-platform-surgeons-nontechnical-skills-performance-improvement
July 01, 2017 - Commentary
The eNOTSS platform for surgeons’ nontechnical skills performance improvement.
Citation Text:
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
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psnet.ahrq.gov/issue/team-checkup-tool-evaluating-qi-team-activities-and-giving-feedback-senior-leaders
November 27, 2012 - Commentary
The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.
Citation Text:
Lubomski LH, Marsteller JA, Hsu Y-J, et al. The team checkup tool: evaluating QI team activities and giving feedback to senior leaders. Jt Comm J Qual Patient Saf. 2008;3…
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psnet.ahrq.gov/issue/new-tool-give-hospitalists-feedback-improve-interprofessional-teamwork-and-advance-patient
February 10, 2015 - Commentary
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.
Citation Text:
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff…
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psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-efforts-assess-progress-and-reduce-risk
May 16, 2018 - Book/Report
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Citation Text:
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed. Washington, DC: United States Gov…
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psnet.ahrq.gov/issue/addressing-prehospital-patient-safety-using-science-injury-prevention-and-control
April 12, 2019 - Commentary
Addressing prehospital patient safety using the science of injury prevention and control.
Citation Text:
Meisel ZF, Hargarten S, Vernick J. Addressing prehospital patient safety using the science of injury prevention and control. Prehosp Emerg Care. 2008;12(4):411-6. doi:10.1…
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psnet.ahrq.gov/issue/teamwork-operating-theatre-cohesion-or-confusion
July 26, 2011 - Study
Teamwork in the operating theatre: cohesion or confusion?
Citation Text:
Undre S, Sevdalis N, Healey A, et al. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12(2):182-9.
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psnet.ahrq.gov/issue/whole-patient-measure-safety-using-administrative-data-assess-probability-highly-undesirable
March 19, 2014 - Study
Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization.
Citation Text:
Perla RJ, Hohmann S, Annis K. Whole-patient measure of safety: using administrative data to assess the probability of highly und…
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psnet.ahrq.gov/issue/framework-classifying-patient-safety-practices-results-expert-consensus-process
September 20, 2011 - Study
A framework for classifying patient safety practices: results from an expert consensus process.
Citation Text:
Dy SM, Taylor SL, Carr LH, et al. A framework for classifying patient safety practices: results from an expert consensus process. BMJ Qual Saf. 2011;20(7):618-24. doi:10…
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psnet.ahrq.gov/issue/enhancing-safety-reporting-adult-ambulatory-oncology-clinician-champion-practice-innovation
January 05, 2017 - Study
Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation.
Citation Text:
Weingart SN, Price J, Duncombe D, et al. Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. J Nurs Care …
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - Study
The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.
Citation Text:
Raab SS, Meier FA, Zarbo RJ, et al. The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer. J Clin Oncol. 2…
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psnet.ahrq.gov/issue/variation-caregiver-perceptions-teamwork-climate-labor-and-delivery-units
August 04, 2021 - Study
Variation in caregiver perceptions of teamwork climate in labor and delivery units.
Citation Text:
Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006;26(8):463-70.
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psnet.ahrq.gov/issue/relational-leadership-perspective-unit-level-safety-climate
April 24, 2018 - Study
A relational leadership perspective on unit-level safety climate.
Citation Text:
Thompson DN, Hoffman LA, Sereika SM, et al. A relational leadership perspective on unit-level safety climate. J Nurs Adm. 2011;41(11):479-87. doi:10.1097/NNA.0b013e3182346e31.
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psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication-and-handoff
August 04, 2021 - Study
Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
Citation Text:
Steinberger DM, Douglas S, Kirschbaum MS. Use of failure mode and effects analysis for proactive identification of…
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psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-care
December 06, 2023 - Commentary
Recommendations to ensure safety of AI in real-world clinical care.
Citation Text:
Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598.
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