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psnet.ahrq.gov/node/35436/psn-pdf
September 15, 2009 - Hospital nurse staffing and patient mortality, emotional
exhaustion, and job dissatisfaction.
September 15, 2009
Halm M, Peterson M, Kandels M, et al. Hospital nurse staffing and patient mortality, emotional exhaustion,
and job dissatisfaction. Clin Nurse Spec. 2005;19(5):241-254.
https://psnet.ahrq.gov/issue/hosp…
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable
Deaths After Injury.
October 21, 2016
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2016.
https://psnet.ahrq.gov/issue/national-trauma-care-system-inte…
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psnet.ahrq.gov/node/38096/psn-pdf
January 02, 2017 - Handoffs causing patient harm: a survey of medical and
surgical house staff.
January 2, 2017
Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical
house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70.
https://psnet.ahrq.gov/issue/handoffs-causing-patient-harm-…
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psnet.ahrq.gov/node/44098/psn-pdf
April 29, 2015 - Evaluation of the suitability of root cause analysis
frameworks for the investigation of community-acquired
pressure ulcers: a systematic review and documentary
analysis.
April 29, 2015
McGraw C, Drennan VM. Evaluation of the suitability of root cause analysis frameworks for the
investigation of community-acquire…
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psnet.ahrq.gov/node/47806/psn-pdf
January 01, 2021 - Pursuing patient safety at the intersection of design,
systems engineering, and health care delivery research:
an ongoing assessment.
February 27, 2019
Henriksen K, Rodrick D, Grace EN, et al. Pursuing Patient Safety at the Intersection of Design, Systems
Engineering, and Health Care Delivery Research: An Ongoing …
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psnet.ahrq.gov/node/47044/psn-pdf
April 18, 2018 - Bedside computer vision—moving artificial intelligence
from driver assistance to patient safety.
April 18, 2018
Yeung S, Downing L, Fei-Fei L, et al. Bedside Computer Vision - Moving Artificial Intelligence from Driver
Assistance to Patient Safety. New Engl J Med. 2018;378(14):1271-1273. doi:10.1056/NEJMp1716891.
…
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psnet.ahrq.gov/node/38625/psn-pdf
November 19, 2009 - The design of the SAFE or SORRY? study: a cluster
randomised trial on the development and testing of an
evidence based inpatient safety program for the
prevention of adverse events.
November 19, 2009
van Gaal BGI, Schoonhoven L, Hulscher M, et al. The design of the SAFE or SORRY? study: a cluster
randomised trial…
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psnet.ahrq.gov/node/34849/psn-pdf
May 14, 2012 - The end of the beginning: patient safety five years after
'To Err Is Human.'
May 14, 2012
Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff.
2004;23(Suppl1). doi:10.1377/hlthaff.w4.534.
https://psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-…
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psnet.ahrq.gov/node/50792/psn-pdf
January 15, 2020 - Lessons learned implementing a complex and innovative
patient safety learning laboratory project in a large
academic medical center
January 15, 2020
Businger AC, Fuller TE, Schnipper JL, et al. Lessons learned implementing a complex and innovative
patient safety learning laboratory project in a large academic medi…
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psnet.ahrq.gov/node/37324/psn-pdf
February 16, 2011 - A complementary approach to promoting
professionalism: identifying, measuring, and addressing
unprofessional behaviors.
February 16, 2011
Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism:
identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82…
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psnet.ahrq.gov/node/41686/psn-pdf
September 19, 2012 - The association between sepsis and potential medical
injury among hospitalized patients.
September 19, 2012
Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among
hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556.
https://psnet.ahrq.gov/issue/as…
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psnet.ahrq.gov/node/38029/psn-pdf
September 03, 2008 - Minimizing surgical error by incorporating objective
assessment into surgical education.
September 3, 2008
Champion HR, Meglan DA, Shair EK. Minimizing Surgical Error by Incorporating Objective Assessment into
Surgical Education. J Am Coll Surg. 2008;207(2). doi:10.1016/j.jamcollsurg.2008.02.038.
https://psnet.ahr…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/readiness.html
May 01, 2017 - Readiness To Partner With Patient and Family Advisers - Patient and Family Engagement in the Surgical Environment Module
As a clinician or staff member, I am ready to work with patient and family advisers when—
|___| I believe in the importance of patient and family participation in planning and d…
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psnet.ahrq.gov/node/44577/psn-pdf
October 21, 2015 - Improving patient safety in clinical oncology: applying
lessons from Normal Accident Theory.
October 21, 2015
Chera BS, Mazur L, Buchanan I, et al. Improving Patient Safety in Clinical Oncology: Applying Lessons
From Normal Accident Theory. JAMA Oncol. 2015;1(7):958-64. doi:10.1001/jamaoncol.2015.0891.
https://psn…
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psnet.ahrq.gov/node/36407/psn-pdf
April 19, 2011 - Adverse events experienced while transferring the
critically ill patient from the emergency department to the
intensive care unit.
April 19, 2011
Gillman L, Leslie G, Williams T, et al. Adverse events experienced while transferring the critically ill patient
from the emergency department to the intensive care unit…
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psnet.ahrq.gov/node/47111/psn-pdf
September 26, 2018 - Inter- and intra-disciplinary collaboration and patient
safety outcomes in U.S. acute care hospital units: a
cross-sectional study.
September 26, 2018
Ma C, Park SH, Shang J. Inter- and intra-disciplinary collaboration and patient safety outcomes in U.S.
acute care hospital units: A cross-sectional study. Int J Nu…
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psnet.ahrq.gov/node/50406/psn-pdf
October 02, 2019 - The co-design, implementation and evaluation of a
serious board game 'PlayDecide patient safety' to educate
junior doctors about patient safety and the importance of
reporting safety concerns
October 2, 2019
Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation and evaluation of a serious board game
'Pl…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-11.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.11. Dissemination of Results from Lean Projects Throughout the Organization
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Cas…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/case-study.html
March 01, 2017 - Antibiotic Stewardship: Case Study Worksheet
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Instructions:
Divide into small groups of two to three people.
Ask each group to work through each part of the case scenario, pausing for discussion before moving to the next section.
Useful R…
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psnet.ahrq.gov/node/45914/psn-pdf
March 20, 2018 - Understanding the multidimensional effects of resident
duty hours restrictions: a thematic analysis of published
viewpoints in surgery.
March 20, 2018
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours
Restrictions: A Thematic Analysis of Published Viewpoints in Su…