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psnet.ahrq.gov/node/50409/psn-pdf
October 02, 2019 - Exploring the relationship between contact frequency,
leader-member relationships, and patient safety culture
October 2, 2019
Anderson AD, Floegel TA, Hofler L, et al. Exploring the Relationship Between Contact Frequency, Leader-
Member Relationships, and Patient Safety Culture. J Nurs Adm. 2019;49(9):441-446.
doi…
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psnet.ahrq.gov/node/46401/psn-pdf
September 13, 2017 - Understanding middle managers' influence in
implementing patient safety culture.
September 13, 2017
Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture.
BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4.
https://psnet.ahrq.gov/issue/understanding-mid…
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psnet.ahrq.gov/node/39832/psn-pdf
September 08, 2010 - Unintended transplantation of three organs from an HIV-
positive donor: report of the analysis of an adverse event
in a regional health care service in Italy.
September 8, 2010
Bellandi T, Albolino S, Tartaglia R, et al. Unintended transplantation of three organs from an HIV-positive
donor: report of the analysis …
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psnet.ahrq.gov/node/73249/psn-pdf
May 12, 2021 - I-PASS handover system: a decade of evidence demands
action.
May 12, 2021
Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf.
2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314.
https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action
The I-PASS structu…
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psnet.ahrq.gov/node/46231/psn-pdf
December 20, 2017 - Patient preferences for participation in patient care and
safety activities in hospitals.
December 20, 2017
Ringdal M, Chaboyer W, Ulin K, et al. Patient preferences for participation in patient care and safety
activities in hospitals. BMC Nurs. 2017;16:69. doi:10.1186/s12912-017-0266-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38736/psn-pdf
June 24, 2009 - Improving patient safety by understanding past
experiences in day surgery and PACU.
June 24, 2009
Ross J, Ranum D. Improving patient safety by understanding past experiences in day surgery and PACU. J
Perianesth Nurs. 2009;24(3):144-51. doi:10.1016/j.jopan.2009.03.001.
https://psnet.ahrq.gov/issue/improving-patien…
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psnet.ahrq.gov/node/34697/psn-pdf
December 08, 2010 - Sentinel events. In memory of Ben—a case study.
December 8, 2010
Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5.
https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
Written from the perspective of a risk manager, the author tells the story of a medication a…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…
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psnet.ahrq.gov/node/37056/psn-pdf
February 24, 2011 - Use of multidisciplinary rounds to simultaneously
improve quality outcomes, enhance resident education,
and shorten length of stay.
February 24, 2011
O'Mahony S, Mazur E, Charney P, et al. Use of multidisciplinary rounds to simultaneously improve quality
outcomes, enhance resident education, and shorten length of …
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digital.ahrq.gov/ahrq-funded-projects/success-stories/building-foundation-health-information-exchange-improve-poison-control
January 01, 2023 - Building a Foundation for Health Information Exchange to Improve Poison Control
Your browser does not support inline frames. Please go to http://youtu.be/lH_i5qRflPM to view the video. Principal Investigator: Mollie Cummins (Grant No. R21 HS018773) [6 min., 03 sec.] This project illustrated…
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psnet.ahrq.gov/node/73189/psn-pdf
April 28, 2021 - Time out! Rethinking surgical safety: more than just a
checklist.
April 28, 2021
Weinger MB. Time out! Rethinking surgical safety: more than just a checklist. BMJ Qual Saf.
2021;30(8):613-617. doi:10.1136/bmjqs-2020-012600.
https://psnet.ahrq.gov/issue/time-out-rethinking-surgical-safety-more-just-checklist
Check…
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psnet.ahrq.gov/node/44396/psn-pdf
January 22, 2016 - Bedside shift-to-shift handoffs: a systematic review of the
literature.
January 22, 2016
Mardis T, Mardis M, Davis JJ, et al. Bedside Shift-to-Shift Handoffs: A Systematic Review of the Literature.
J Nurs Care Qual. 2016;31(1):54-60. doi:10.1097/NCQ.0000000000000142.
https://psnet.ahrq.gov/issue/bedside-shift-shif…
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psnet.ahrq.gov/node/42580/psn-pdf
September 11, 2013 - To disclose or not to disclose radiologic errors: should
"patient-first" supersede radiologist self-interest?
September 11, 2013
Berlin L. To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self-
interest? Radiology. 2013;268(1):4-7. doi:10.1148/radiol.13130193.
https://…
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psnet.ahrq.gov/node/73585/psn-pdf
August 11, 2021 - Breast cancer screening and overdiagnosis.
August 11, 2021
Bulliard J?L, Beau A?B, Njor S, et al. Breast cancer screening and overdiagnosis. Int J Cancer.
2021;149(4):846-853. doi:10.1002/ijc.33602.
https://psnet.ahrq.gov/issue/breast-cancer-screening-and-overdiagnosis
Overdiagnosis of breast cancer and the result…
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psnet.ahrq.gov/node/844757/psn-pdf
September 11, 2019 - Diagnostic overshadowing in dentistry.
September 11, 2019
Clough S, Handley P. Diagnostic overshadowing in dentistry. Br Dent J. 2019;227(4):311-315.
doi:10.1038/s41415-019-0623-x.
https://psnet.ahrq.gov/issue/diagnostic-overshadowing-dentistry
Assumptions, communication barriers, and implicit biases can compromis…
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psnet.ahrq.gov/node/72559/psn-pdf
December 09, 2020 - The Life and Death of Elizabeth Dixon: A Catalyst for
Change.
December 9, 2020
Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.
https://psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
Missed diagnosis of a dangerous condition in utero, treatment errors, lack of respons…
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psnet.ahrq.gov/node/44327/psn-pdf
August 26, 2015 - Safely Home: What Happens When People Leave Hospital
Care Settings?
August 26, 2015
London, UK: Healthwatch England; July 2015.
https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…
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psnet.ahrq.gov/node/34100/psn-pdf
February 09, 2011 - Safety of patients isolated for infection control.
February 9, 2011
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA.
2003;290(14):1899-1905.
https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control
This study discovered that patients isolated for coloniza…
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psnet.ahrq.gov/node/72534/psn-pdf
December 02, 2020 - Patients' perceptions of safety in emergency medical
services: an interview study.
December 2, 2020
Venesoja A, Castrén M, Tella S, et al. Patients’ perceptions of safety in emergency medical services: an
interview study. BMJ Open. 2020;10(10):e037488. doi:10.1136/bmjopen-2020-037488.
https://psnet.ahrq.gov/issue/…
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www.ahrq.gov/action-alliance/webinars/psychological-safety.html
March 01, 2025 - National Action Alliance Webinar: Establishing Psychological Safety for Healthcare Workers
Creating and Maintaining a Culture of Safety Series (Session 1)
This webinar was the first of a three-part series on Safety Culture in Healthcare. On February 18, 2025, experts shared how leadership rounding with staff …