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psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing-education
September 09, 2015 - Commentary
Conducting root cause analysis with nursing students: best practice in nursing education.
Citation Text:
Lambton J, Mahlmeister L. Conducting root cause analysis with nursing students: best practice in nursing education. J Nurs Educ. 2010;49(8):444-8. doi:10.3928/01484834-…
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psnet.ahrq.gov/issue/should-patients-get-direct-access-their-laboratory-test-results-answer-many-questions
November 13, 2024 - Commentary
Should patients get direct access to their laboratory test results?: An answer with many questions.
Citation Text:
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.10…
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psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-series
April 29, 2018 - Commentary
Unintended errors with EHR-based result management: a case series.
Citation Text:
Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294.
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psnet.ahrq.gov/issue/description-inpatient-medication-management-using-cognitive-work-analysis
October 19, 2022 - Study
Description of inpatient medication management using cognitive work analysis.
Citation Text:
Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181b…
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psnet.ahrq.gov/issue/incomplete-care-trail-flaws-system
February 17, 2011 - Commentary
Incomplete care—on the trail of flaws in the system.
Citation Text:
Gandhi TK, Zuccotti G, Lee TH. Incomplete care--on the trail of flaws in the system. N Engl J Med. 2011;365(6):486-8. doi:10.1056/NEJMp1106313.
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psnet.ahrq.gov/issue/what-value-and-impact-quality-and-safety-teams-scoping-review
December 06, 2017 - Review
What is the value and impact of quality and safety teams? A scoping review.
Citation Text:
White DE, Straus SE, Stelfox T, et al. What is the value and impact of quality and safety teams? A scoping review. Implement Sci. 2011;6:97. doi:10.1186/1748-5908-6-97.
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psnet.ahrq.gov/issue/educational-and-audit-tool-reduce-prescribing-error-intensive-care
August 04, 2021 - Study
An educational and audit tool to reduce prescribing error in intensive care.
Citation Text:
Thomas AN, Boxall EM, Laha SK, et al. An educational and audit tool to reduce prescribing error in intensive care. Qual Saf Health Care. 2008;17(5):360-3. doi:10.1136/qshc.2007.023242.
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psnet.ahrq.gov/issue/new-legal-protections-reporting-patient-errors-under-patient-safety-and-quality-improvement
November 16, 2022 - Review
New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature and analysis.
Citation Text:
Howard J, Levy F, Mareiniss DP, et al. New legal protections for reporting patient errors under the Patient Sa…
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psnet.ahrq.gov/issue/redesigning-morbidity-and-mortality-program-university-affiliated-pediatric-anesthesia
March 27, 2024 - Commentary
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.
Citation Text:
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/why-it-so-hard-reduce-harm-medicines
April 28, 2021 - Commentary
Why is it so hard to reduce harm from medicines?
Citation Text:
Rochford A. Why is it so hard to reduce harm from medicines? Future Healthc J. 2024;11(4):100205. doi:10.1016/j.fhj.2024.100205.
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psnet.ahrq.gov/issue/patient-safety-consumers-perspective
January 12, 2022 - Study
Patient safety: a consumer's perspective.
Citation Text:
Hovey RB, Dvorak ML, Burton T, et al. Patient safety: a consumer's perspective. Qual Health Res. 2011;21(5):662-72. doi:10.1177/1049732311399779.
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psnet.ahrq.gov/issue/medication-safety-just-label-away
August 18, 2021 - Commentary
Medication safety: just a label away.
Citation Text:
Jennings J, Foster J. Medication safety: just a label away. AORN J. 2007;86(4):618-25.
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Dow…
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psnet.ahrq.gov/issue/set-phasers-stun-and-other-true-tales-design-technology-and-human-error-second-edition
May 30, 2019 - Book/Report
Classic
Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition.
Citation Text:
Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. Casey SM. Santa Barbara, CA: Ae…
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psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
September 29, 2017 - Book/Report
Classic
Identification and Prioritization of Health IT Patient Safety Measures.
Citation Text:
Identification and Prioritization of Health IT Patient Safety Measures. Washington, DC: National Quality Forum; February 2016.
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psnet.ahrq.gov/issue/barriers-implementation-patient-safety-systems-healthcare-institutions-leadership-and-policy
July 14, 2010 - Study
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications.
Citation Text:
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. Akins RB, Cole BR. J Patient …
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psnet.ahrq.gov/node/50391/psn-pdf
September 25, 2019 - complication risk, and increased cost.11-13 Therefore, surgeons should be engaged early in the
clinical decision-making
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Feedback domains included overall teamwork, communication, situational awareness, leadership, and decision-making … They had better communication, decision-making, accuracy, and so forth.
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - They had better communication, decision-making, accuracy, and so forth. … Feedback domains included overall teamwork, communication, situational awareness, leadership, and decision-making
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psnet.ahrq.gov/web-mm/picking-cause-stroke
August 07, 2024 - recently introduced MAGIC guidelines offer an evidence-based approach to improve vascular access device decision-making
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Management/Engagement, Engaging in Collaborative Practice, Difficult Conversations, and Teamwork and
Decision-Making