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psnet.ahrq.gov/issue/swiss-cheese-model
March 27, 2005 - August 2, 2016
Score Your Safety Culture.
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psnet.ahrq.gov/issue/alliance-innovation-maternal-health
July 26, 2017 - September 13, 2017
Just Culture, Medication Error Prevention, and Second Victim Support
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psnet.ahrq.gov/issue/toolkit-improving-perinatal-safety
May 01, 2017 - Resources
Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture
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psnet.ahrq.gov/issue/ibeas-pioneer-study-patient-safety-latin-america-towards-safer-hospital-care
January 29, 2019 - February 18, 2009
Building a Culture of Patient Safety: Report of the Commission on Patient
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psnet.ahrq.gov/issue/quality-special-issue
April 13, 2022 - radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture
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psnet.ahrq.gov/issue/improving-diagnosis-teenage-cancer-trust-report-improving-diagnostic-experience-young-people
November 20, 2013 - July 24, 2024
Improving Patient Safety Culture – A Practical Guide.
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psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
March 27, 2005 - Related Resources From the Same Author(s)
The Challenger Launch Decision: Risky Technology, Culture
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psnet.ahrq.gov/issue/failure-safety-critical-systems-handbook-accident-and-incident-reporting
November 23, 2016 - June 2, 2010
The Challenger Launch Decision: Risky Technology, Culture, and Deviance
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psnet.ahrq.gov/issue/lyme-disease-baffling-even-experts-new-insights-are-last-accumulating
August 19, 2020 - October 16, 2019
The influence of organizational culture, climate and commitment on speaking
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psnet.ahrq.gov/issue/spotlight-electronic-health-record-errors-errors-related-use-default-values
February 11, 2014 - September 18, 2013
Promote a culture of safety with good catch reports.
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psnet.ahrq.gov/issue/identifying-risks-and-monitoring-safety-role-patients-and-citizens
May 08, 2013 - June 6, 2012
Culture, language, and patient safety: making the link.
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - means of data collection and reporting
Reviewing best practices
Understanding patient and provider culture … improved provider performance
A bottom-up approach to change that includes an understanding of unit culture … , nursing attitudes and
beliefs, and patient preferences and how each of these factors affect medication … Survey staff on their attitudes and beliefs regarding VTE prophylaxis.
Define measures and goals. … Hidden barriers to delivery of pharmacological venous
thromboembolism prophylaxis: the role of nursing beliefs
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and culture … that is that organizations can start to deviate from established procedures and bend them if in their culture … The culture created at the top is more important than any number of experts that you have there. … Japan's culture made it harder to discuss the risk.
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - Workplace culture and human resource availability are common barriers to best practices To understand … Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Workplace
culture and human resource availability are common barriers to best practices. … • Numerous barriers to reporting exist including fear of consequences, a culture of
blame, perception … errors in a user-friendly and non-punitive
manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/node/46328/psn-pdf
August 09, 2017 - Critical incident stress debriefing after adverse patient
safety events.
August 9, 2017
Harrison R, Wu AW. Critical incident stress debriefing after adverse patient safety events. Am J Med Qual.
2017;23(5):310-312.
https://psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events…
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psnet.ahrq.gov/node/47039/psn-pdf
September 12, 2018 - Overdiagnosis in primary care: framing the problem and
finding solutions.
September 12, 2018
Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ.
2018;362:k2820. doi:10.1136/bmj.k2820.
https://psnet.ahrq.gov/issue/overdiagnosis-primary-care-framing-problem-and-findi…
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psnet.ahrq.gov/node/39870/psn-pdf
September 22, 2010 - Is it time to pull the plug on 12-hour shifts?: Part 3. Harm
Reduction Strategies if Keeping 12-Hour Shifts.
September 22, 2010
Geiger-Brown J, Trinkoff AM. Is it time to pull the plug on 12-hour shifts? Part 3. harm reduction strategies
if keeping 12-hour shifts. J Nurs Adm. 2010;40(9):357-9. doi:10.1097/NNA.0b013…
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psnet.ahrq.gov/node/39529/psn-pdf
June 02, 2010 - Patient safety in primary care has many aspects: an
interview study in primary care doctors and nurses.
June 2, 2010
Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview
study in primary care doctors and nurses. J Eval Clin Pract. 2010;16(3):639-43. doi:10.1111/j.…
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psnet.ahrq.gov/node/38063/psn-pdf
February 23, 2009 - CPOE in Iran—a viable prospect? Physicians' opinions on
using CPOE in an Iranian teaching hospital.
February 23, 2009
Kazemi A, Ellenius J, Tofighi S, et al. CPOE in Iran--a viable prospect? Physicians' opinions on using
CPOE in an Iranian teaching hospital. Int J Med Inform. 2009;78(3):199-207.
doi:10.1016/j.ijme…