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psnet.ahrq.gov/issue/why-patient-safety-such-tough-nut-crack
May 03, 2023 - Commentary
Why patient safety is such a tough nut to crack.
Citation Text:
Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. BMJ. 2011;342:d3447. doi:10.1136/bmj.d3447.
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psnet.ahrq.gov/issue/towards-model-surgeons-leadership-operating-room
July 01, 2020 - Review
Towards a model of surgeons' leadership in the operating room.
Citation Text:
Parker SH, Yule S, Flin R, et al. Towards a model of surgeons' leadership in the operating room. BMJ Qual Saf. 2011;20(7):570-9. doi:10.1136/bmjqs.2010.040295.
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psnet.ahrq.gov/issue/help-your-patient-get-what-you-just-said-health-literacy-guide
December 18, 2014 - Commentary
Help your patient "get" what you just said: a health literacy guide.
Citation Text:
Roett MA, Wessel L. Help your patient "get" what you just said: a health literacy guide. J Family Pract. 2012;61(4):190-196.
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psnet.ahrq.gov/issue/simulation-based-training-patient-safety-10-principles-matter
January 02, 2017 - Review
Simulation-based training for patient safety: 10 principles that matter.
Citation Text:
Salas E, Wilson KA, Lazzara EH, et al. Simulation-Based Training for Patient Safety. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e3181656dd6.
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psnet.ahrq.gov/issue/improving-emergency-department-discharge-process
April 23, 2014 - Book/Report
Improving the Emergency Department Discharge Process.
Citation Text:
Improving the Emergency Department Discharge Process. Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.…
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psnet.ahrq.gov/issue/harms-promoting-zero-harm
February 12, 2020 - Commentary
Emerging Classic
The harms of promoting 'Zero Harm'.
Citation Text:
Thomas EJ. The harms of promoting ‘Zero Harm’. BMJ Qual Saf. 2019;29(1):4-6. doi:10.1136/bmjqs-2019-009703.
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psnet.ahrq.gov/issue/sleep-deprivation-call-institutional-rules
June 27, 2018 - Commentary
Sleep deprivation: a call for institutional rules.
Citation Text:
McKenna L, Kodner IJ, Healy GB, et al. Sleep deprivation: a call for institutional rules. Surgery. 2013;154(1):118-22.
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psnet.ahrq.gov/issue/perchance-think
December 08, 2016 - Commentary
Perchance to think.
Citation Text:
Ofri D. Perchance to Think. New Engl J Med. 2019;380(13):1197-1199. doi:10.1056/NEJMp1814019.
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psnet.ahrq.gov/issue/unreported-errors-intensive-care-unit-case-study-way-we-work
December 12, 2012 - Commentary
Unreported errors in the intensive care unit: a case study of the way we work.
Citation Text:
Henneman EA. Unreported errors in the intensive care unit: a case study of the way we work. Crit Care Nurse. 2007;27(5):27-34; quiz 35.
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psnet.ahrq.gov/issue/health-information-technology-engaging-patients-diagnostic-decision-making-emergency
April 22, 2020 - Book/Report
Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.
Citation Text:
Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments. Mangus CW, Singh H, Mahajan P. Rockville, MD:…
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psnet.ahrq.gov/issue/silence-kills-seven-crucial-conversations-healthcare
July 09, 2012 - Book/Report
Silence Kills: The Seven Crucial Conversations for Healthcare.
Citation Text:
Silence Kills: The Seven Crucial Conversations for Healthcare. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Provo, UT: VitalSmarts, L.C; 2005.
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psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hinge-approach-success
December 08, 2021 - Commentary
Reducing surgical errors: implementing a three-hinge approach to success.
Citation Text:
Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J. 2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013.
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psnet.ahrq.gov/issue/reducing-medical-errors-and-adverse-events
March 21, 2012 - Review
Reducing medical errors and adverse events.
Citation Text:
Pham JC, Aswani MS, Rosen MA, et al. Reducing medical errors and adverse events. Annu Rev Med. 2012;63:447-63. doi:10.1146/annurev-med-061410-121352.
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psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit
December 16, 2020 - Special or Theme Issue
Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.
Citation Text:
Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(s…
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psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety
April 23, 2012 - Study
Nurses' sleep, work hours, and patient care quality, and safety
Citation Text:
Nurses' sleep, work hours, and patient care quality, and safety Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320.
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psnet.ahrq.gov/issue/practical-tool-learn-defects-patient-care
September 28, 2010 - Commentary
A practical tool to learn from defects in patient care.
Citation Text:
Pronovost P, Holzmueller CG, Martinez EA, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-108.
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psnet.ahrq.gov/issue/does-simulation-improve-patient-safety-self-efficacy-competence-operational-performance-and
May 25, 2016 - Commentary
Does simulation improve patient safety?: self-efficacy, competence, operational performance, and patient safety.
Citation Text:
Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. A…
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psnet.ahrq.gov/issue/building-high-reliability-teams-progress-and-some-reflections-teamwork-training
March 21, 2017 - Commentary
Building high reliability teams: progress and some reflections on teamwork training.
Citation Text:
Salas E, Rosen MA. Building high reliability teams: progress and some reflections on teamwork training. BMJ Qual Saf. 2013;22(5):369-73. doi:10.1136/bmjqs-2013-002015.
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psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared-profession-wide-system
December 01, 2021 - Commentary
Patient safety performance: reversing recent declines through shared profession-wide system-level solutions.
Citation Text:
doi:full/10.1056/CAT.22.0318.
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - Cognitive Errors
Trying to perform a cognitive autopsy to understand why the resident committed the … Armed with this understanding, they can apply cognitive
forcing strategies to reduce the occurrence … In doing so, hospitals should strive to implement a universal cognitive forcing
strategy to always verify … Cognitive forcing strategies in clinical decisionmaking. … The importance of cognitive errors in diagnosis and strategies to minimize them.