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psnet.ahrq.gov/node/867597/psn-pdf
January 22, 2025 - A coaching program to improve employee engagement,
culture of safety, and patient experience.
January 22, 2025
Scheurer D, Coulter A, Harper K, et al. A coaching program to improve employee engagement, culture of
safety, and patient experience. NEJM Catalyst. 2024;6(1):CAT.24.0225. doi:10.1056/cat.24.0225.
https:/…
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psnet.ahrq.gov/node/42942/psn-pdf
February 22, 2024 - Targeted Medication Safety Best Practices for Hospitals.
February 22, 2024
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2024.
https://psnet.ahrq.gov/issue/targeted-medication-safety-best-practices-hospitals
This updated report outlines 22 consensus-based best practices to ensure safe medication ad…
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psnet.ahrq.gov/node/73581/psn-pdf
January 01, 2022 - Applying human factors engineering to address the
telemetry alarm problem in a large medical center.
August 11, 2021
Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry
alarm problem in a large medical center. Hum Factors. 2022;64(1):126-142.
doi:10.1177/001872082…
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psnet.ahrq.gov/node/48087/psn-pdf
July 10, 2019 - The rise of human factors: optimising performance of
individuals and teams to improve patients' outcomes.
July 10, 2019
Casali G, Cullen W, Lock G. The rise of human factors: optimising performance of individuals and teams to
improve patients' outcomes. J Thorac Dis. 2019;11(Suppl 7):S998-S1008. doi:10.21037/jtd.20…
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psnet.ahrq.gov/node/844039/psn-pdf
February 08, 2023 - Using potentially preventable severe maternal morbidity
to monitor hospital performance.
February 8, 2023
Fridman M, Korst LM, Reynen DJ, et al. Using potentially preventable severe maternal morbidity to monitor
hospital performance. Jt Comm J Qual Patient Saf. 2023;49(3):129-137. doi:10.1016/j.jcjq.2022.11.007.
h…
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psnet.ahrq.gov/node/60794/psn-pdf
August 12, 2020 - Communication with patients and families regarding
health care-associated exposure to coronavirus 2019: a
checklist to facilitate disclosure.
August 12, 2020
Sivashanker K, Mendu ML, Wickner PG, et al. Communication with patients and families regarding health
care-associated exposure to coronavirus 2019: a checkli…
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psnet.ahrq.gov/node/73135/psn-pdf
April 14, 2021 - Debrief it all: a tool for inclusion of Safety-II.
April 14, 2021
Bentley SK, McNamara S, Meguerdichian MJ, et al. Debrief it all: a tool for inclusion of Safety-II. Adv Simul
(Lond). 2021;6(1):9. doi:10.1186/s41077-021-00163-3.
https://psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii
Debriefing is a c…
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psnet.ahrq.gov/node/46113/psn-pdf
July 12, 2017 - Optimizing a Business Case for Safe Health Care: An
Integrated Approach to Safety and Finance.
July 12, 2017
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-in…
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psnet.ahrq.gov/node/73166/psn-pdf
April 21, 2021 - Trust and medical AI: the challenges we face and the
expertise needed to overcome them.
April 21, 2021
Quinn TP, Senadeera M, Jacobs S, et al. Trust and medical AI: the challenges we face and the expertise
needed to overcome them. J Amer Med Inform Assoc. 2021;28(4):890-894. doi:10.1093/jamia/ocaa268.
https://psne…
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psnet.ahrq.gov/node/866282/psn-pdf
July 10, 2024 - Artificial intelligence can be regulated using current
patient safety procedures and infrastructure in hospitals.
July 10, 2024
Fleisher LA, Economou-Zavlanos NJ. Artificial intelligence can be regulated using current patient safety
procedures and infrastructure in hospitals. JAMA Health Forum. 2024;5(6):e241369.
…
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psnet.ahrq.gov/node/72821/psn-pdf
March 10, 2019 - I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources.
March 10, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources. MedEdPORTAL. 2018;14(1):10736. doi:10.15766/mep_2374-
8265.10736.
https://psnet.ahr…
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psnet.ahrq.gov/node/842420/psn-pdf
January 11, 2023 - Using the Assessment of Reasoning Tool to facilitate
feedback about diagnostic reasoning.
January 11, 2023
Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about
diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-2022-0020.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45859/psn-pdf
August 03, 2017 - Root cause analysis and actions for the prevention of
medical errors: quality improvement and resident
education.
August 3, 2017
Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical
Errors: Quality Improvement and Resident Education. Orthopedics. 2017;40(4):e628-e635…
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psnet.ahrq.gov/node/46793/psn-pdf
February 28, 2018 - Patient safety movement: history and future directions.
February 28, 2018
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg
Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
https://psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
The pati…
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psnet.ahrq.gov/node/45879/psn-pdf
July 02, 2017 - A hybrid methodology for modeling risk of adverse
events in complex health-care settings.
July 2, 2017
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex
Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
https://psnet.ahrq.gov/issue/hybrid-m…
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psnet.ahrq.gov/node/38057/psn-pdf
September 10, 2008 - Randomized controlled trial of a pictogram-based
intervention to reduce liquid medication dosing errors
and improve adherence among caregivers of young
children.
September 10, 2008
Yin S, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention to
reduce liquid medication do…
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psnet.ahrq.gov/node/40693/psn-pdf
January 08, 2016 - A framework for engaging physicians in quality and
safety.
January 8, 2016
Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf.
2012;21(9):722-728. doi:10.1136/bmjqs-2011-000167.
https://psnet.ahrq.gov/issue/framework-engaging-physicians-quality-and-safety
Promoti…
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psnet.ahrq.gov/node/36068/psn-pdf
September 28, 2010 - Getting doctors to report medical errors: project
DISCLOSE.
September 28, 2010
King ES, Moyer D, Couturie MJ, et al. Getting doctors to report medical errors: project DISCLOSE. Jt
Comm J Qual Patient Saf. 2006;32(7):382-392.
https://psnet.ahrq.gov/issue/getting-doctors-report-medical-errors-project-disclose
This …
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
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psnet.ahrq.gov/node/50375/psn-pdf
September 25, 2019 - Medical error in the care of the unrepresented: disclosure
and apology for a vulnerable patient population.
September 25, 2019
Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable
patient population. J Med Ethics. 2019;45(12):821-823. doi:10.1136/medethics-2019-10…