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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/45841/psn-pdf
March 01, 2017 - Monitoring the anaesthetist in the operating
theatre—professional competence and patient safety.
March 1, 2017
Larsson J. Monitoring the anaesthetist in the operating theatre - professional competence and patient
safety. Anaesthesia. 2017;72 Suppl 1:76-83. doi:10.1111/anae.13743.
https://psnet.ahrq.gov/issue/monit…
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psnet.ahrq.gov/node/47979/psn-pdf
May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists
to improve diagnosis.
May 1, 2019
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor
Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/37444/psn-pdf
January 02, 2008 - My brother's keeper: must a physician disclose another's
medical error and potential negligence?
January 2, 2008
Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and
potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10.1016/j.jclinane.2007.05.005.
https://p…
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psnet.ahrq.gov/node/43585/psn-pdf
July 16, 2015 - At risk care plans: a way to reduce readmissions and
adverse events.
July 16, 2015
Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse
events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106.
https://psnet.ahrq.gov/issue/risk-care-plans-way-reduc…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/checklist-creating.html
May 01, 2017 - Checklist for Creating an Observation Tool - Coaching Clinical Teams Module
This checklist can help you in each step of creating your observation tool.
Development
(Before Drafting Your Tool)
→
Drafting
(Before Testing Your Tool)
→
Testing
(Before Using Your Tool)
…
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psnet.ahrq.gov/node/45993/psn-pdf
January 01, 2021 - 30-day potentially avoidable readmissions due to adverse
drug events.
May 3, 2017
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse
Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
https://psnet.ahrq.gov/issue/30-day-potentially-a…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
March 01, 2017 - Learn From Defects
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety
Who should use this tool? Senior l…
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psnet.ahrq.gov/node/44118/psn-pdf
May 19, 2018 - Inadequate preoperative team briefings lead to more
intraoperative adverse events.
May 19, 2018
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative
Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
https://psnet.ahrq.gov/issue/inadequate-…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/836726/psn-pdf
March 09, 2022 - OpenNotes and patient safety: a perilous voyage into
uncharted waters.
March 9, 2022
Schust G, Manning M, Weil A. OpenNotes and patient safety: a perilous voyage into uncharted waters. J
Gen Intern Med. 2022;37(8):2074-2076. doi:10.1007/s11606-021-07384-2.
https://psnet.ahrq.gov/issue/opennotes-and-patient-safety-…
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psnet.ahrq.gov/node/37737/psn-pdf
January 06, 2017 - Can patient safety be measured by surveys of patient
experiences?
January 6, 2017
Solberg LI, Asche SE, Averbeck BM, et al. Can patient safety be measured by surveys of patient
experiences? Jt Comm J Qual Patient Saf. 2008;34(5):266-274.
https://psnet.ahrq.gov/issue/can-patient-safety-be-measured-surveys-patient-e…
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psnet.ahrq.gov/node/45713/psn-pdf
November 22, 2017 - Assigning responsibility to close the loop on radiology
test results.
November 22, 2017
Kwan JL, Singh H. Assigning responsibility to close the loop on radiology test results. Diagnosis (Berl).
2017;4(3):173-177. doi:10.1515/dx-2017-0019.
https://psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-t…
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psnet.ahrq.gov/node/74753/psn-pdf
February 09, 2022 - The morbidity and mortality conference: opportunities for
enhancing patient safety.
February 9, 2022
Lazzara EH, Salisbury M, Hughes AM, et al. The morbidity and mortality conference: opportunities for
enhancing patient safety. J Patient Saf. 2022;18(1):e275-e281. doi:10.1097/pts.0000000000000765.
https://psnet.ah…
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section9.html
October 01, 2015 - Resident Physicians as Champions in Preventing Device-Associated Infections
Plan To Help Incorporate the Role of Champions for Resident Physicians
Previous Page Next Page
Table of Contents
Resident Physicians as Champions in Preventing Device-Associated Infections
Preamble and Summary
Epidemiolo…
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psnet.ahrq.gov/node/61089/psn-pdf
January 01, 2021 - Cognitive bias impact on management of postoperative
complications, medical error, and standard of care.
November 4, 2020
Antonacci AC, Dechario SP, Antonacci C, et al. Cognitive bias impact on management of postoperative
complications, medical error, and standard of care. J Surg Res. 2021;258:47-53.
doi:10.1016/j…
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psnet.ahrq.gov/node/43830/psn-pdf
February 04, 2015 - A combined teamwork training and work standardisation
intervention in operating theatres: controlled interrupted
time series study.
February 4, 2015
Morgan L, Pickering S, Hadi M, et al. A combined teamwork training and work standardisation intervention
in operating theatres: controlled interrupted time series stu…
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psnet.ahrq.gov/node/47237/psn-pdf
January 01, 2020 - First-year analysis of the Operating Room Black Box
study.
July 25, 2018
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg.
2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
An…
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psnet.ahrq.gov/node/34654/psn-pdf
June 16, 2011 - Risk mitigation in large scale systems: lessons from high
reliability organizations.
June 16, 2011
Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-161.
https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
The authors examine high-reliability organizations,…