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psnet.ahrq.gov/node/863759/psn-pdf
March 06, 2024 - Clinician responses to disruptive intraoperative
behaviour: patterns and norms identified from a
multinational survey.
March 6, 2024
Villafranca A, Fast I, Turick M, et al. Clinician responses to disruptive intraoperative behaviour: patterns
and norms identified from a multinational survey. Can J Anaesth. 2024;71(…
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psnet.ahrq.gov/node/47021/psn-pdf
May 02, 2018 - The impact of improving teamwork on patient outcomes
in surgery: a systematic review.
May 2, 2018
Sun R, Marshall DC, Sykes MC, et al. The impact of improving teamwork on patient outcomes in surgery: A
systematic review. Int J Surg. 2018;53:171-177. doi:10.1016/j.ijsu.2018.03.044.
https://psnet.ahrq.gov/issue/impa…
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psnet.ahrq.gov/node/34755/psn-pdf
September 06, 2011 - Safe Practices for Better Healthcare: 2006 Update.
September 6, 2011
Washington DC: National Quality Forum; 2007.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
The National Quality Forum used expert consensus and evidence review to identify 30 health care “safe
practices” that should be…
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psnet.ahrq.gov/node/73922/psn-pdf
October 06, 2021 - Leading causes of anesthesia-related liability claims in
ambulatory surgery centers.
October 6, 2021
Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory
surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/60234/psn-pdf
April 15, 2020 - Mistakes, Errors and Failures across Cultures.
April 15, 2020
Vanderheiden E, Mayer C, eds. Springer Nature. Cham, Switzerland: 2020. ISBN 9783030355739
https://psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials
Human error, mistakes and failure have cultural aspects that are im…
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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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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/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/46611/psn-pdf
January 01, 2021 - Sustaining teamwork behaviors through reinforcement of
TeamSTEPPS principles.
November 15, 2017
Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of
TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414.
https://psnet.ahrq.gov/issue/…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-15.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.15. Major Factors that Inhibited Lean Success
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Cas…