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psnet.ahrq.gov/node/38545/psn-pdf
April 22, 2009 - Burns surgery handover study: trainees' assessment of
current practice in the British Isles.
April 22, 2009
Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns surgery handover study: trainees' assessment of current
practice in the British Isles. Burns. 2009;35(4):509-12. doi:10.1016/j.burns.2008.11.008.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45311/psn-pdf
May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd
Edition.
May 20, 2019
Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.
https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition
Checklists are a widely accepted strategy to improve communication and standardize processes to su…
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psnet.ahrq.gov/node/50874/psn-pdf
February 05, 2020 - Checking In on the Checklist.
February 5, 2020
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
https://psnet.ahrq.gov/issue/checking-checklist
Checklists are integrated into error reduction strategies and healthcare team communication efforts
worldwide but implementation and impact of the tool varies …
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psnet.ahrq.gov/node/851926/psn-pdf
August 02, 2023 - Improving Patient Safety Culture – A Practical Guide.
August 2, 2023
London, UK: NHS England; July 2023.
https://psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining
improvements. This toolkit pro…
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psnet.ahrq.gov/node/39182/psn-pdf
May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in
obstetrics and gynecology.
May 22, 2019
Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in
obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e.
https://psnet.ahrq.gov/issue/acog-com…
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psnet.ahrq.gov/node/38325/psn-pdf
September 29, 2017 - Health care professionals' views of implementing a policy
of open disclosure of errors.
September 29, 2017
Sorensen R, Iedema R, Piper D, et al. Health care professionals' views of implementing a policy of open
disclosure of errors. J Health Serv Res Policy. 2008;13(4):227-32. doi:10.1258/jhsrp.2008.008062.
https:…
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psnet.ahrq.gov/node/40885/psn-pdf
November 26, 2014 - Hospital do-not-resuscitate orders: why they have failed
and how to fix them.
November 26, 2014
Yuen JK, Reid C, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them.
J Gen Intern Med. 2011;26(7):791-7. doi:10.1007/s11606-011-1632-x.
https://psnet.ahrq.gov/issue/hospital-do-not-…
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psnet.ahrq.gov/node/60948/psn-pdf
September 23, 2020 - Without an 'ounce of empathy': their stories show the
dangers of being Black and pregnant.
September 23, 2020
Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.
https://psnet.ahrq.gov/issue/without-ounce-empathy-their-stories-show-dangers-being-black-and-pregnant
Implicit and explicit biases …
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psnet.ahrq.gov/node/45110/psn-pdf
May 11, 2016 - Hospital discharge: it's one of the most dangerous
periods for patients.
May 11, 2016
Rau J. Washington Post. April 29, 2016.
https://psnet.ahrq.gov/issue/hospital-discharge-its-one-most-dangerous-periods-patients
Transitions in care between inpatient and outpatient settings are an increasing concern for patient s…
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psnet.ahrq.gov/node/866357/psn-pdf
July 24, 2024 - People’s Experiences of Diagnosis.
July 24, 2024
People’s Experiences Of Diagnosis. London, England: National Voices; June 2024.
https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis
The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report
explores the diagnosti…
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psnet.ahrq.gov/node/45646/psn-pdf
November 23, 2016 - Patient safety in the emergency department.
November 23, 2016
Farmer B. Patient Safety in the Emergency Department. Emerg Med (N Y). 2016;48(9).
doi:10.12788/emed.2016.0052.
https://psnet.ahrq.gov/issue/patient-safety-emergency-department
Emergency departments are high-risk environments due to the urgency of care …
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psnet.ahrq.gov/node/39634/psn-pdf
December 04, 2016 - We meant no harm, yet we made a mistake; why not
apologize for it? A student's view.
December 4, 2016
Sanford DE, Fleming DA. We meant no harm, yet we made a mistake; why not apologize for it? A student's
view. HEC Forum. 2010;22(2):159-69. doi:10.1007/s10730-010-9131-8.
https://psnet.ahrq.gov/issue/we-meant-no-ha…
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psnet.ahrq.gov/node/43152/psn-pdf
May 07, 2014 - The trainee's voice: recognising the importance of
preoperative briefings for surgical trainees.
May 7, 2014
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for
surgical trainees. J Perioper Pract. 2014;24(3):56-58.
https://psnet.ahrq.gov/issue/trainees-voice-recog…
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psnet.ahrq.gov/node/37751/psn-pdf
June 29, 2011 - Using nurses and office staff to report prescribing errors
in primary care.
June 29, 2011
Kennedy AG, Littenberg B, Senders JW. Using nurses and office staff to report prescribing errors in
primary care. Int J Qual Health Care. 2008;20(4):238-45. doi:10.1093/intqhc/mzn015.
https://psnet.ahrq.gov/issue/using-nurses…
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psnet.ahrq.gov/node/865820/psn-pdf
May 08, 2024 - Breaking the silence on medical mistakes.
May 8, 2024
Scott M. The Pulse. New York Public Radio; April 26, 2024.
https://psnet.ahrq.gov/issue/breaking-silence-medical-mistakes
Individuals involved in medical errors need time and support to process the incident and its consequences.
This moderated podcast examines …
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psnet.ahrq.gov/node/73326/psn-pdf
June 01, 2021 - CANDOR Webinar Series.
June 1, 2021
Patient Safety Movement Foundation. 2021.
https://psnet.ahrq.gov/issue/candor-webinar-series
The Communication and Optimal Resolution (CANDOR) model was designed to support early error
disclosure with patients and families after mistakes in care occur. This three-part webi…
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psnet.ahrq.gov/node/42438/psn-pdf
July 31, 2013 - Perceived patient safety culture in a critical care transport
program.
July 31, 2013
Erler C, Edwards NE, Ritchey S, et al. Perceived patient safety culture in a critical care transport program.
Air Med J. 2013;32(4):208-215. doi:10.1016/j.amj.2012.11.002.
https://psnet.ahrq.gov/issue/perceived-patient-safety-cult…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-18.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.18. Key Facilitators and Barriers to Organizing and Implementing Lean at Grand Hospital Center (from Conceptual Framework)
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case S…
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www.ahrq.gov/nursing-home/resources/trauma-informed.html
May 01, 2021 - Trauma-Informed Organizational Change Manual
Resource: Trauma-Informed Organizational Change Manual
This manual guides organizations and systems in planning for, implementing and sustaining a trauma-informed organizational change. This manual provides a step-by-step guide with tools intended for anyone inte…
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psnet.ahrq.gov/node/60829/psn-pdf
August 19, 2020 - Patient Safety.
August 19, 2020
Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.
https://psnet.ahrq.gov/issue/patient-safety-20
Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair
of special issues highlights the use of simulation in nur…