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psnet.ahrq.gov/issue/bridging-communication-gap-operating-room-medical-team-training
March 05, 2025 - Study
Bridging the communication gap in the operating room with medical team training.
Citation Text:
Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-4.
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psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
November 17, 2021 - Study
The effects of physical environments in medical wards on medication communication processes affecting patient safety.
Citation Text:
Liu W, Manias E, Gerdtz M. The effects of physical environments in medical wards on medication communication processes affecting patient safety. Heal…
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psnet.ahrq.gov/issue/error-management-lessons-aviation
September 13, 2011 - Commentary
Classic
On error management: lessons from aviation.
Citation Text:
Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785.
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Format:
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psnet.ahrq.gov/issue/implementing-standardized-reporting-and-safety-checklists
September 29, 2017 - Study
Implementing standardized reporting and safety checklists.
Citation Text:
Stevens JD, Bader MK, Luna MA, et al. Cultivating quality: implementing standardized reporting and safety checklists. Am J Nurs. 2011;111(5):48-53. doi:10.1097/01.naj.0000398051.07923.69.
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psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system
November 23, 2014 - Study
Implementing SBAR across a large multihospital health system.
Citation Text:
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-8.
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psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes
March 11, 2015 - Press Release/Announcement
Infections associated with reprocessed flexible bronchoscopes.
Citation Text:
Infections associated with reprocessed flexible bronchoscopes. FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
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psnet.ahrq.gov/issue/fda-requires-label-warnings-prohibit-sharing-multi-dose-diabetes-pen-devices-among-patients
March 04, 2015 - Press Release/Announcement
FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients.
Citation Text:
FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients. FDA Safety Communication. Silver Spring, MD: US …
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psnet.ahrq.gov/issue/interventions-improve-communication-hospital-discharge-and-rates-readmission-systematic
January 12, 2022 - Review
Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis.
Citation Text:
Becker C, Zumbrunn S, Beck K, et al. Interventions to improve communication at hospital discharge and rates of readmission. JAMA Netw Open. …
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psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during
April 12, 2011 - Study
Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.
Citation Text:
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…
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psnet.ahrq.gov/issue/transforming-communication-and-safety-culture-intrapartum-care-multi-organization-blueprint
May 21, 2019 - Commentary
Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.
Citation Text:
Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(…
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psnet.ahrq.gov/issue/nurses-communication-safety-events-nursing-home-residents-and-families
September 23, 2020 - Study
Nurses' communication of safety events to nursing home residents and families.
Citation Text:
Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002…
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psnet.ahrq.gov/issue/cardinal-health-recalls-argyle-uvc-insertion-tray-due-missing-instructions-use-safety-scalpel
August 20, 2021 - Press Release/Announcement
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.
Citation Text:
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11. MedWatch Safety Al…
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psnet.ahrq.gov/issue/how-do-patients-and-care-partners-describe-diagnostic-uncertainty-emergency-department-or
October 23, 2024 - Study
How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent care setting?
Citation Text:
DeGennaro AP, Gonzalez N, Peterson SM, et al. How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent c…
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - Timely written orders and progress notes also serve to
communicate the patient’s care needs and health
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-items.pdf
January 01, 2015 - Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items
SOPS
TM
Ambulatory Surgery Center Survey
Items and Composites
Version: 1.0
Language: English
Note
• For more information on getting started, selecting a sample, determining data collection methods,
establish…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
June 01, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action
Inpatient-to-Outpatient Transitions
Previous Page Next Page
Table of Contents
Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to A…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-leadership.pptx
January 05, 2022 - Module 4: Leadership
Module 4
Leadership To Improve Diagnosis
TeamSTEPPS® for Diagnosis Improvement
Welcome to the TeamSTEPPS for Diagnosis Improvement course. This presentation will cover Module 4, Leadership To Improve Diagnosis, that you will review as the course facilitator.
Individuals who plan to take the…
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psnet.ahrq.gov/node/46652/psn-pdf
July 14, 2018 - The effects of crew resource management on teamwork
and safety climate at Veterans Health Administration
facilities.
July 14, 2018
Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource management on teamwork and
safety climate at Veterans Health Administration facilities. J Healthc Risk Manag. 2018;…