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psnet.ahrq.gov/node/60968/psn-pdf
September 30, 2020 - Assisting beginners in root cause analysis operations:
analysis and recommendations regarding the spread of
COVID-19 in nursing facilities for the elderly.
September 30, 2020
Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations
regarding the spread of COVID-19 in nursing …
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psnet.ahrq.gov/node/46400/psn-pdf
September 06, 2017 - The Charter on Professionalism for Health Care
Organizations.
September 6, 2017
Egener BE, Mason DJ, McDonald WJ, et al. The Charter on Professionalism for Health Care
Organizations. Acad Med. 2017;92(8):1091-1099. doi:10.1097/ACM.0000000000001561.
https://psnet.ahrq.gov/issue/charter-professionalism-health-care-o…
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psnet.ahrq.gov/node/43566/psn-pdf
December 19, 2014 - Bedside shift reports: what does the evidence say?
December 19, 2014
Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm.
2014;44(10):541-5. doi:10.1097/NNA.0000000000000115.
https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say
Bedside shift report…
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psnet.ahrq.gov/node/34589/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. System
innovation: Veterans Health Administration National
Center for Patient Safety.
January 4, 2017
Heget JR, Bagian JP, Lee CZ, et al. John M. Eisenberg Patient Safety Awards. System innovation:
Veterans Health Administration National Center for Patient Safety. Jt Comm J…
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psnet.ahrq.gov/node/73351/psn-pdf
June 02, 2021 - Optimising the delivery of remediation programmes for
doctors: a realist review.
June 2, 2021
Price T, Wong G, Withers L, et al. Optimising the delivery of remediation programmes for doctors: a realist
review. Med Educ. 2021;55(9):995-1010. doi:10.1111/medu.14528.
https://psnet.ahrq.gov/issue/optimising-delivery-r…
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psnet.ahrq.gov/node/41229/psn-pdf
March 04, 2015 - The Triangle Model for evaluating the effect of health
information technology on healthcare quality and safety.
March 4, 2015
Ancker JS, Kern LM, Abramson EL, et al. The Triangle Model for evaluating the effect of health information
technology on healthcare quality and safety. J Am Med Inform Assoc. 2012;19(1):61-5…
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psnet.ahrq.gov/node/38346/psn-pdf
April 01, 2010 - Human factors engineering in healthcare systems: the
problem of human error and accident management.
April 1, 2010
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and
accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005.
http…
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psnet.ahrq.gov/node/46158/psn-pdf
October 31, 2017 - Improving care teams' functioning: recommendations
from team science.
October 31, 2017
Fiscella K, Mauksch L, Bodenheimer T, et al. Improving Care Teams' Functioning: Recommendations from
Team Science. Jt Comm J Qual Patient Saf. 2017;43(7):361-368. doi:10.1016/j.jcjq.2017.03.009.
https://psnet.ahrq.gov/issue/impr…
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psnet.ahrq.gov/node/74734/psn-pdf
January 19, 2024 - Disclosure of errors in surgical procedures.
January 19, 2024
Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
https://psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
Error disclosure is fundamental to addressing harm and psychological distress after medical error. This
review highlights issues a…
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psnet.ahrq.gov/node/47185/psn-pdf
June 27, 2018 - Why we need a single definition of disruptive behavior.
June 27, 2018
Petrovic MA, Scholl AT. Why We Need a Single Definition of Disruptive Behavior. Cureus.
2018;10(3):e2339. doi:10.7759/cureus.2339.
https://psnet.ahrq.gov/issue/why-we-need-single-definition-disruptive-behavior
Disruptive behavior affects patient…
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psnet.ahrq.gov/node/60799/psn-pdf
August 12, 2020 - Good and bad reasons: the Swiss cheese model and its
critics.
August 12, 2020
Larouzee J, Le Coze J-C. Good and bad reasons: the Swiss cheese model and its critics. Safety Sci.
2020;126:104660. doi:10.1016/j.ssci.2020.104660.
https://psnet.ahrq.gov/issue/good-and-bad-reasons-swiss-cheese-model-and-its-critics
Thi…
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psnet.ahrq.gov/node/46675/psn-pdf
April 12, 2019 - The hidden curricula of medical education: a scoping
review.
April 12, 2019
Lawrence C, Mhlaba T, Stewart KA, et al. The Hidden Curricula of Medical Education: A Scoping Review.
Acad Med. 2018;93(4):648-656. doi:10.1097/ACM.0000000000002004.
https://psnet.ahrq.gov/issue/hidden-curricula-medical-education-scoping-r…
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psnet.ahrq.gov/node/44073/psn-pdf
April 15, 2015 - Clinician support: five years of lessons learned.
April 15, 2015
Hirschinger LE, Scott SD, Hahn-Cover K. Patient Saf Qual Heathc. April 2015;12:26-31.
https://psnet.ahrq.gov/issue/clinician-support-five-years-lessons-learned
This magazine article relates insights from an academic health care system that developed a…
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psnet.ahrq.gov/node/42000/psn-pdf
March 06, 2013 - Measurement and training of TeamSTEPPS dimensions
using the Medical Team Performance Assessment Tool.
March 6, 2013
Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the
Medical Team Performance Assessment Tool. Jt Comm J Qual Patient Saf. 2013;39(2):89-95.
https://psnet…
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/44053/psn-pdf
November 16, 2015 - ANA CAUTI Prevention Tool.
November 16, 2015
Silver Spring, MD: American Nurses Association; 2015.
https://psnet.ahrq.gov/issue/ana-cauti-prevention-tool
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This
toolkit, developed as a Partnership for Patients strategy, …
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psnet.ahrq.gov/node/44629/psn-pdf
December 09, 2015 - Toolkit for Reducing CAUTI in Hospitals.
December 9, 2015
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
https://psnet.ahrq.gov/issue/toolkit-reducing-cauti-hospitals
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients.
This toolkit was …
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psnet.ahrq.gov/node/42153/psn-pdf
April 03, 2013 - Creating an infrastructure for safety event reporting and
analysis in a multicenter pediatric emergency department
network.
April 3, 2013
Chamberlain JM, Shaw KN, Lillis KA, et al. Creating an infrastructure for safety event reporting and
analysis in a multicenter pediatric emergency department network. Pediatr Em…
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psnet.ahrq.gov/node/45058/psn-pdf
February 18, 2017 - Learning from incidents in healthcare: the journey, not
the arrival, matters.
February 18, 2017
Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival,
matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853.
https://psnet.ahrq.gov/issue/learni…
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psnet.ahrq.gov/node/35966/psn-pdf
January 02, 2017 - Assessing and monitoring override medications in
automated dispensing devices.
January 2, 2017
Kowiatek JG, Weber RJ, Skledar S, et al. Assessing and monitoring override medications in automated
dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-17.
https://psnet.ahrq.gov/issue/assessing-and-monitoring…