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psnet.ahrq.gov/node/856588/psn-pdf
November 29, 2023 - It depends who you ask: divergences in staff and external
stakeholder narratives about the causes of a healthcare
failure.
November 29, 2023
Hald EJ, Gillespie A, Reader TW. It depends who you ask: divergences in staff and external stakeholder
narratives about the causes of a healthcare failure. J Contingencies Cr…
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psnet.ahrq.gov/node/50627/psn-pdf
November 06, 2019 - Change?of?shift nursing handoff interruptions:
implications for evidence?based practice.
November 6, 2019
Rhudy LM, Johnson MR, Krecke CA, et al. Change-of-Shift Nursing Handoff Interruptions: Implications for
Evidence-Based Practice. Worldviews Evid Based Nurs. 2019;16(5):362-370. doi:10.1111/wvn.12390.
https://p…
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psnet.ahrq.gov/node/866313/psn-pdf
July 17, 2024 - Towards understanding and improving medication safety
for patients with mental illness in primary care: a
multimethod study.
July 17, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. Towards understanding and improving medication safety for patients
with mental illness in primary care: a multimethod study. Health Expect.…
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psnet.ahrq.gov/node/35229/psn-pdf
January 02, 2017 - Patient Safety Leadership WalkRounds™ at Partners
HealthCare: learning from implementation.
January 2, 2017
Frankel A, Grillo SP, Baker EG, et al. Patient Safety Leadership WalkRounds at Partners Healthcare:
learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-37.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/35451/psn-pdf
January 05, 2017 - Closing the loop: follow-up and feedback in a patient
safety program.
January 5, 2017
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety
program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
https://psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-pati…
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psnet.ahrq.gov/node/861765/psn-pdf
January 31, 2024 - Observational study of conformity in yet another medical
learning environment: conformity to preceptors during
high-fidelity simulation.
January 31, 2024
Beran T, Altabbaa G, Oddone Paolucci E. Observational study of conformity in yet another medical
learning environment: conformity to preceptors during high-fidel…
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psnet.ahrq.gov/node/47896/psn-pdf
July 10, 2019 - Engaging patients and informal caregivers to improve
safety and facilitate person- and family-centered care
during transitions from hospital to home: a qualitative
descriptive study.
July 10, 2019
Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety and facilitate
person- and family…
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psnet.ahrq.gov/node/849325/psn-pdf
January 01, 2024 - Medication safety event reporting: factors that contribute
to safety events during times of organizational stress.
May 24, 2023
Cohen TN, Berdahl CT, Coleman BL, et al. Medication safety event reporting: factors that contribute to
safety events during times of organizational stress. J Nurs Care Qual. 2024;39(1):51-…
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psnet.ahrq.gov/node/837731/psn-pdf
July 27, 2022 - Predictors and outcomes of patient safety culture: a
cross-sectional comparative study.
July 27, 2022
Mrayyan MT. Predictors and outcomes of patient safety culture: a cross-sectional comparative study. BMJ
Open Qual. 2022;11(3):e001889. doi:10.1136/bmjoq-2022-001889.
https://psnet.ahrq.gov/issue/predictors-and-out…
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psnet.ahrq.gov/node/60536/psn-pdf
May 27, 2020 - Nursing home workers warned government about safety
violations before COVID-19 outbreaks and deaths.
May 27, 2020
Ellis B, Hicken M. CNN. May 14, 2020.
https://psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19-
outbreaks-and-deaths
Long-term care and skilled nursing faci…
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psnet.ahrq.gov/node/50917/psn-pdf
February 19, 2020 - "Thank You for Listening": An exploratory study
regarding the lived experience and perception of medical
errors among those who receive care.
February 19, 2020
Terry D, Kim J-ah, Gilbert J, et al. “Thank You for Listening”: An Exploratory Study Regarding the Lived
Experience and Perception of Medical Errors Among …
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psnet.ahrq.gov/node/47121/psn-pdf
August 08, 2018 - Assessment of programs aimed to decrease or prevent
mistreatment of medical trainees.
August 8, 2018
Mazer LM, Bereknyei Merrell S, Hasty BN, et al. Assessment of Programs Aimed to Decrease or Prevent
Mistreatment of Medical Trainees. JAMA Netw Open. 2018;1(3):e180870.
doi:10.1001/jamanetworkopen.2018.0870.
https…
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psnet.ahrq.gov/node/866563/psn-pdf
August 21, 2024 - Leadership and the high reliability transformation: a
qualitative study at Truman VA medical center.
August 21, 2024
Leonard C, Gilmartin HM, Starr LM, et al. Leadership and the high reliability transformation: a qualitative
study at Truman VA medical center. J Healthc Risk Manag. 2024;44(1):17-23. doi:10.1002/jhrm…
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psnet.ahrq.gov/node/74109/psn-pdf
November 24, 2021 - Patient and caregiver factors in ambulatory incident
reports: a mixed-methods analysis.
November 24, 2021
Sharma AE, Huang B, Del Rosario JB, et al. Patient and caregiver factors in ambulatory incident reports: a
mixed-methods analysis. BMJ Open Qual. 2021;10(3):e001421. doi:10.1136/bmjoq-2021-001421.
https://psne…
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psnet.ahrq.gov/node/40816/psn-pdf
March 21, 2017 - Professionalism: a necessary ingredient in a culture of
safety.
March 21, 2017
Dupree E, Anderson R, McEvoy MD, et al. Professionalism: a necessary ingredient in a culture of safety. Jt
Comm J Qual Patient Saf. 2011;37(10):447-55.
https://psnet.ahrq.gov/issue/professionalism-necessary-ingredient-culture-safety
Di…
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psnet.ahrq.gov/node/73133/psn-pdf
April 14, 2021 - A human factors intervention in a hospital--evaluating the
outcome of a TeamSTEPPS program in a surgical ward.
April 14, 2021
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. A human factors intervention in a hospital - evaluating the
outcome of a TeamSTEPPS program in a surgical ward. BMC Health Serv Res. 2021;21(1):11…
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psnet.ahrq.gov/node/73679/psn-pdf
September 08, 2021 - Why an open disclosure procedure is and is not followed
after an avoidable adverse event.
September 8, 2021
Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is not followed after an
avoidable adverse event. J Patient Saf. 2021;17(6):e529-e533. doi:10.1097/pts.0000000000000405.
https…
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psnet.ahrq.gov/node/839826/psn-pdf
November 09, 2022 - Professional behavior and value erosion: a qualitative
study of physicians and the electronic health record.
November 9, 2022
Skeff KM, Brown-Johnson CG, Asch SM, et al. Professional behavior and value erosion: a qualitative study
of physicians and the electronic health record. J Healthc Manag. 2022;67(5):339-352. …
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psnet.ahrq.gov/node/841473/psn-pdf
December 14, 2022 - Examination of maternal near-miss experiences in the
hospital setting among Black women in the United States.
December 14, 2022
Byrd TE, Ingram LA, Okpara N. Examination of maternal near-miss experiences in the hospital setting
among Black women in the United States. Womens Health (Lond). 2022;18:174550572211338.
…
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psnet.ahrq.gov/node/34656/psn-pdf
May 27, 2011 - A look into the nature and causes of human errors in the
intensive care unit.
May 27, 2011
Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care
unit. Crit Care Med. 1995;23(2):294-300.
https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-…