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psnet.ahrq.gov/node/73365/psn-pdf
June 09, 2021 - Enhancing psychological safety in mental health services.
June 9, 2021
Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment
Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1.
https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…
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psnet.ahrq.gov/node/41228/psn-pdf
August 02, 2012 - Identifying the latent failures underpinning medication
administration errors: an exploratory study.
August 2, 2012
Lawton R, Carruthers S, Gardner P, et al. Identifying the latent failures underpinning medication
administration errors: an exploratory study. Health Serv Res. 2012;47(4):1437-1459. doi:10.1111/j.1475…
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www.ahrq.gov/action-alliance/webinars/measuring-safety-culture.html
May 01, 2025 - Measuring and Responding to Safety Culture Across Healthcare
This webinar was the third of a three-part series on Safety Culture in Healthcare. On April 15, 2025, presenters discussed how to measure and improve safety culture using tools like AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Program, the Safety…
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psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
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psnet.ahrq.gov/node/60992/psn-pdf
October 14, 2020 - Another medical malpractice crisis?: Try something
different.
October 14, 2020
Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different.
JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557.
https://psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-d…
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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/node/40745/psn-pdf
September 07, 2011 - A prospective observational study of physician handoff
for intensive-care-unit-to-ward patient transfers.
September 7, 2011
Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care-
Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). doi:10.1016/j.amjmed.2011.04.027.
…
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psnet.ahrq.gov/node/48039/psn-pdf
August 07, 2019 - Utilization of a role-based head covering system to
decrease misidentification in the operating room.
August 7, 2019
Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease
Misidentification in the Operating Room. J Patient Saf. 2019;15(4):e90-e93.
doi:10.1097/PTS.00000…
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psnet.ahrq.gov/node/50593/psn-pdf
October 30, 2019 - Using video to assess and improve patient safety during
simulated and actual neonatal resuscitation.
October 30, 2019
Leone TA. Using video to assess and improve patient safety during simulated and actual neonatal
resuscitation. Semin Perinatol. 2019;43(8):151179. doi:10.1053/j.semperi.2019.08.008.
https://psnet.a…
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psnet.ahrq.gov/node/47775/psn-pdf
April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic
management teams.
April 3, 2019
Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic
Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121.
https://psnet.ahrq.gov/issue/reducing-diagnostic-error…
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psnet.ahrq.gov/node/46562/psn-pdf
April 16, 2018 - "To err is human" but disclosure must be taught: a
simulation-based assessment study.
April 16, 2018
Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation-
Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.0000000000000273.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38544/psn-pdf
September 02, 2009 - A pilot study examining undesirable events among
emergency department–boarded patients awaiting
inpatient beds.
September 2, 2009
Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency
department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-5.
do…
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psnet.ahrq.gov/node/47583/psn-pdf
December 05, 2018 - Interpersonal and organizational dynamics are key drivers
of failure to rescue.
December 5, 2018
Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of
Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/852278/psn-pdf
August 09, 2023 - Identifying failure modes in telemedicine: an instructional
needs assessment.
August 9, 2023
Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs
assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/46663/psn-pdf
November 29, 2017 - ISMP survey shows provider text messaging often runs
afoul of patient safety.
November 29, 2017
ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5.
https://psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety
Texting medication orders is convenient …
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psnet.ahrq.gov/node/45506/psn-pdf
November 30, 2016 - Is an indication-based prescribing system in our future?
November 30, 2016
ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
Health information technology has enhanced prescribers' ability to document the purpose o…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2019_hpchartbook_infographic.pdf
January 01, 2019 - 2019 CAHPS Health Plan Survey Database Chartbook Executive Summary
CAHPS® 2019 Health Plan Survey Database
This overview of resu lts summarizes how health plan enrollees across all
populations rate their health plan based on the 2019 Consumer Assessment of
Healthcare Providers and Systems (CAHPS®) Health Plan S…
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www.ahrq.gov/hai/cusp/modules/apply/index.html
July 01, 2018 - Apply CUSP
The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPPS communication tools.
This module…
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www.ahrq.gov/cahps/surveys-guidance/outpatient-mental-health/about/survey-measures.html
October 01, 2024 - CAHPS Outpatient Mental Health Survey Measures
For more information: Patient Experience Measures from the Outpatient Mental Health Survey (PDF, 219 KB) Getting Appointments for Prescription Medicines Q3 Difficulty making appointments for prescription medicine Getting Mental Health Counseling Q10 Difficulty fi…
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psnet.ahrq.gov/node/50827/psn-pdf
January 22, 2020 - Becoming a high-reliability organization through shared
learning of safety events
January 22, 2020
Klenklen J. Patient Saf Qual HCare. December 19, 2019.
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
High reliability organizations consistently examine wha…