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psnet.ahrq.gov/node/46466/psn-pdf
July 11, 2018 - Distinct newborn identification requirement.
July 11, 2018
R3 Report. June 25, 2018;7:1-2.
https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement
Neonatal patients are at risk for misidentification due to communication challenges and lack of
distinguishable features. This report highlights new Jo…
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psnet.ahrq.gov/node/40424/psn-pdf
May 04, 2011 - Evaluation of postoperative handover using a tool to
assess information transfer and teamwork.
May 4, 2011
Nagpal K, Abboudi M, Fischler L, et al. Ann Surg. 2011;253:831-837.
https://psnet.ahrq.gov/issue/evaluation-postoperative-handover-using-tool-assess-information-transfer-and-
teamwork
Handoffs of patients af…
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psnet.ahrq.gov/node/42070/psn-pdf
March 11, 2013 - Implementing peer evaluation of handoffs: associations
with experience and workload.
March 11, 2013
Arora V, Greenstein EA, Woodruff JN, et al. Implementing peer evaluation of handoffs: associations with
experience and workload. J Hosp Med. 2013;8(3):132-6. doi:10.1002/jhm.2002.
https://psnet.ahrq.gov/issue/implem…
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psnet.ahrq.gov/node/40460/psn-pdf
April 30, 2024 - Patient Safety Authority Annual Reports.
April 30, 2024
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2024.
https://psnet.ahrq.gov/issue/patient-safety-authority-annual-reports
This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews th…
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psnet.ahrq.gov/node/50633/psn-pdf
November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in
assessment to ensure their safety. This re…
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psnet.ahrq.gov/node/844756/psn-pdf
September 18, 2019 - Emerging Concepts in Patient Safety.
September 18, 2019
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
https://psnet.ahrq.gov/issue/emerging-concepts-patient-safety
This publication presents patient safety concepts for anesthesia practice, including decision aids to educate
and empower patients about anesthe…
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psnet.ahrq.gov/node/36188/psn-pdf
March 28, 2011 - Role of medical students in preventing patient harm and
enhancing patient safety.
March 28, 2011
Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient
safety. Qual Saf Health Care. 2006;15(4):272-6.
https://psnet.ahrq.gov/issue/role-medical-students-preventing-patie…
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psnet.ahrq.gov/node/46448/psn-pdf
September 27, 2017 - Simulation in Otolaryngology.
September 27, 2017
Malekzadeh S, ed. Otolaryngol Clin North Am. 2017;50(5):xv-xviii, 875-1036.
https://psnet.ahrq.gov/issue/simulation-otolaryngology
This special issue highlights areas in otolaryngology where simulation is being used to develop
multidisciplinary team-based approaches…
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psnet.ahrq.gov/node/39028/psn-pdf
October 21, 2009 - The content and context of change of shift report on
medical and surgical units.
October 21, 2009
Staggers N, Jennings BM. The content and context of change of shift report on medical and surgical units.
J Nurs Adm. 2009;39(9):393-8. doi:10.1097/NNA.0b013e3181b3b63a.
https://psnet.ahrq.gov/issue/content-and-contex…
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psnet.ahrq.gov/node/46500/psn-pdf
June 27, 2018 - Ariadne Labs.
June 27, 2018
Brigham & Women's Hospital; Harvard T.H. Chan School of Public Health.
https://psnet.ahrq.gov/issue/ariadne-labs
Checklists can help catch gaps in communication and process. This website provides resources related to
the use of checklists in surgical, obstetric, and other care environme…
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psnet.ahrq.gov/node/36914/psn-pdf
March 21, 2017 - Reasons for after-hours calls by hospital floor nurses to
on-call physicians.
March 21, 2017
Bernstam E, Pancheri KK, Johnson CM, et al. Reasons for after-hours calls by hospital floor nurses to on-
call physicians. Jt Comm J Qual Patient Saf. 2007;33(6):342-9.
https://psnet.ahrq.gov/issue/reasons-after-hours-call…
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psnet.ahrq.gov/node/41769/psn-pdf
October 17, 2012 - The MacArthur Fellows Program: Eric Coleman.
October 17, 2012
MacArthur Foundation.
https://psnet.ahrq.gov/issue/macarthur-fellows-program-eric-coleman
Dr. Eric Coleman has enhanced care transitions by developing tools and processes to improve
communication and reduce readmissions. The MacArthur Foundation has sel…
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psnet.ahrq.gov/node/45735/psn-pdf
July 17, 2017 - CMPA Good Practices Guide.
July 17, 2017
Ottawa, Ontario: Canadian Medical Protective Association; 2016.
https://psnet.ahrq.gov/issue/cmpa-good-practices-guide
Key patient safety topics include human factors, teamwork, adverse events, communication,
professionalism, and risk management. This website provides resou…
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psnet.ahrq.gov/node/42584/psn-pdf
September 11, 2013 - Cardiac surgical ICU care: eliminating "preventable"
complications.
September 11, 2013
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications.
J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
https://psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-p…
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psnet.ahrq.gov/node/41543/psn-pdf
January 18, 2013 - Research on nursing handoffs for medical and surgical
settings: an integrative review.
January 18, 2013
Staggers N, Blaz JW. Research on nursing handoffs for medical and surgical settings: an integrative
review. J Adv Nurs. 2013;69(2):247-62. doi:10.1111/j.1365-2648.2012.06087.x.
https://psnet.ahrq.gov/issue/resea…
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psnet.ahrq.gov/node/42601/psn-pdf
September 18, 2013 - 'You talking to me?' Docs and feedback.
September 18, 2013
Diamond F. 'You talking to me?' Docs and feedback. Managed care (Langhorne, Pa.). 2013;22(7):30-2.
https://psnet.ahrq.gov/issue/you-talking-me-docs-and-feedback
Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaki…
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psnet.ahrq.gov/node/40838/psn-pdf
September 27, 2016 - Cognitive Factors in Health Care.
September 27, 2016
Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.
https://psnet.ahrq.gov/issue/cognitive-factors-health-care
Articles in this special issue explore the impact of cognition on health care activities such as patient
identification, interruptions, and team com…
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psnet.ahrq.gov/node/60191/psn-pdf
April 01, 2020 - Unprofessional Behavior Leads to Complications.
April 1, 2020
Unprofessional Behavior Leads to Complications. JN Learning. 2020.
https://psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork.
This educa…
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psnet.ahrq.gov/node/39094/psn-pdf
June 09, 2011 - Human factors in surgery: from Three Mile Island to the
operating room.
June 9, 2011
D'Addessi A, Bongiovanni L, Volpe A, et al. Human factors in surgery: from Three Mile Island to the
operating room. Urol Int. 2009;83(3):249-57. doi:10.1159/000241662.
https://psnet.ahrq.gov/issue/human-factors-surgery-three-mile-…
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psnet.ahrq.gov/node/43113/psn-pdf
April 09, 2014 - Transforming the health care environment collaborative.
April 9, 2014
Burgess C, Curry MP. Transforming the health care environment collaborative. AORN J. 2014;99(4):529-
39. doi:10.1016/j.aorn.2014.01.012.
https://psnet.ahrq.gov/issue/transforming-health-care-environment-collaborative
This commentary examines the…