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psnet.ahrq.gov/node/838924/psn-pdf
October 26, 2022 - Intraoperative code blue: improving teamwork and code
response through interprofessional, in situ simulation.
October 26, 2022
Wu G, Podlinski L, Wang C, et al. Intraoperative code blue: improving teamwork and code response
through interprofessional, in situ simulation. Jt Comm J Qual Patient Saf. 2022;48(12):665-6…
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psnet.ahrq.gov/node/35361/psn-pdf
July 16, 2009 - Improving Patient Safety Through Informed Consent for
Patients with Limited Health Literacy.
July 16, 2009
Wu HW, Nishimi RY, Page-Lopez CM, et al. Washington DC: National Quality Forum; 2005.
https://psnet.ahrq.gov/issue/improving-patient-safety-through-informed-consent-patients-limited-health-
literacy
In the 2…
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psnet.ahrq.gov/node/47841/psn-pdf
April 24, 2019 - Criminalisation of unintentional error in healthcare in the
UK: a perspective from New Zealand.
April 24, 2019
Ameratunga R, Klonin H, Vaughan J, et al. Criminalisation of unintentional error in healthcare in the UK: a
perspective from New Zealand. BMJ. 2019;364:l706. doi:10.1136/bmj.l706.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/73595/psn-pdf
August 11, 2021 - Safety committees need to proactively address the risk of
accidental cerebral injection of intravenous (IV) drugs.
August 11, 2021
ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.
https://psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection-
…
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psnet.ahrq.gov/node/838145/psn-pdf
September 21, 2022 - Charlie Bourg was on the lookout for veterans harmed by
a new VA computer system. He didn’t expect to be one of
them.
September 21, 2022
Donovan-Smith O. Spokesman-Review. September 11, 2022.
https://psnet.ahrq.gov/issue/charlie-bourg-was-lookout-veterans-harmed-new-va-computer-system-he-
didnt-expect-be-one…
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psnet.ahrq.gov/node/50686/psn-pdf
January 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors'
interview accounts of allowing trainee failure while
guarding patient safety.
November 20, 2019
Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview
accounts of allowing trainee failure while guarding p…
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psnet.ahrq.gov/node/50820/psn-pdf
January 22, 2020 - Associations between a new disruptive behaviors scale
and teamwork, patient safety, work-life balance, burnout,
and depression.
January 22, 2020
Rehder KJ, Adair KC, Hadley A, et al. Associations Between a New Disruptive Behaviors Scale and
Teamwork, Patient Safety, Work-Life Balance, Burnout, and Depression. Jt C…
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psnet.ahrq.gov/node/44220/psn-pdf
June 10, 2015 - Building a Culture of Patient Safety Through Simulation:
An Interprofessional Learning Model.
June 10, 2015
Gallo K, Smith LG, eds. New York, NY: Springer Publishing Company; 2015. ISBN: 9780826169068.
https://psnet.ahrq.gov/issue/building-culture-patient-safety-through-simulation-interprofessional-learning-
model…
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psnet.ahrq.gov/node/867759/psn-pdf
March 12, 2025 - Intrahospital patient transport: checklists, adverse
events, and other considerations for the anesthesia
professional.
March 12, 2025
Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other
considerations for the anesthesia professional. APSF Newsletter. 2025;40(1):24-26.
ht…
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psnet.ahrq.gov/node/848086/psn-pdf
April 26, 2023 - Preventable harm in the Canadian organ donation and
transplantation system: a descriptive study of missed
organ donor identification and referral.
April 26, 2023
Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and
transplantation system: a descriptive study of missed orga…
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psnet.ahrq.gov/node/867015/psn-pdf
October 23, 2024 - Supporting perioperative safety during a disaster through
clinical crisis education.
October 23, 2024
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis
education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
https://psnet.ahrq.gov/issue/supporting-…
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psnet.ahrq.gov/node/41607/psn-pdf
January 03, 2017 - Using a risk assessment approach to determine which
factors influence whether partially bilingual physicians
rely on their non-English language skills or call an
interpreter.
January 3, 2017
Maul L, Regenstein M, Andres E, et al. Using a risk assessment approach to determine which factors
influence whether partia…
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www.ahrq.gov/patient-safety/settings/hospital/resource/index.html
February 01, 2025 - Hospitals and Health Systems
Tools and resources for Hospitals, Long-term Care Facilities, and Primary Care Facilities
Hospital Resources Toolkits, recommendations, and other resources for hospitals and hospital administrators to improve quality, reduce errors, and increase patient safety. Communication and O…
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digital.ahrq.gov/funding-mechanism/novel-high-impact-studies-evaluating-health-system-and-healthcare-professional
January 01, 2023 - Novel, High-Impact Studies Evaluating Health System and Healthcare Professional Responsiveness to COVID-19 (R01)
The Role of Telehealth in COVID-19 Response
Description
This research, using data from the country’s largest telehealth provider and claims from a large commercial…
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psnet.ahrq.gov/node/846150/psn-pdf
March 15, 2023 - Patient and health care professional perspectives on
stigma in integrated behavioral health: barriers and
recommendations.
March 15, 2023
Phelan SM, Salinas M, Pankey T, et al. Patient and health care professional perspectives on stigma in
integrated behavioral health: barriers and recommendations. Ann Fam Med. 20…
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psnet.ahrq.gov/node/854988/psn-pdf
November 01, 2023 - Use of design thinking and human factors approach to
improve situation awareness in the pediatric intensive
care unit.
November 1, 2023
Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve
situation awareness in the pediatric intensive care unit. J Hosp Med. 2023;18(1…
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psnet.ahrq.gov/node/72660/psn-pdf
January 20, 2021 - An in situ simulation program: a quantitative and
qualitative prospective study identifying latent safety
threats and examining participant experiences.
January 20, 2021
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. An in situ simulation program: a quantitative and
qualitative prospective study identifying …
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/866408/psn-pdf
July 31, 2024 - Influences of leadership, organizational culture, and
hierarchy on raising concerns about patient deterioration:
a qualitative study.
July 31, 2024
Vehvilainen E, Charles A, Sainsbury J, et al. Influences of leadership, organizational culture, and hierarchy
on raising concerns about patient deterioration: a qualit…
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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…