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psnet.ahrq.gov/issue/finding-and-preventing-patient-safety-incidents
October 25, 2013 - Book/Report
Finding and Preventing Patient Safety Incidents.
Citation Text:
Finding and Preventing Patient Safety Incidents. Golden, CO: HealthGrades, Inc.; June 9, 2014.
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psnet.ahrq.gov/issue/hospital-drug-errors-far-uncommon
February 11, 2015 - Newspaper/Magazine Article
Hospital drug errors far from uncommon.
Citation Text:
Hospital drug errors far from uncommon. Lin R-G II; Watanabe T.
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psnet.ahrq.gov/issue/medical-error-reporting-system-could-boost-patient-safety
December 14, 2022 - Newspaper/Magazine Article
Medical Error Reporting System Could Boost Patient Safety.
Citation Text:
Medical Error Reporting System Could Boost Patient Safety. Ebright PR; Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment, School of Public and Environmental Affa…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
July 01, 2023 - Tool: Check-Back (or Repeat-Back)
A check-back, which is sometimes called a repeat-back, is a closed-loop communication strategy used to verify and validate exchanged information. When a team member calls out information, they typically anticipate a check-back in response to verify that the information was rece…
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psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
August 14, 2017 - Commentary
Preventing harm from high-alert medications.
Citation Text:
Federico F. Preventing harm from high-alert medications. Jt Comm J Qual Patient Saf. 2007;33(9):537-42.
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psnet.ahrq.gov/issue/clinician-mindfulness-and-patient-safety
November 10, 2010 - Commentary
Clinician mindfulness and patient safety.
Citation Text:
Sibinga EMS, Wu AW. Clinician Mindfulness and Patient Safety. JAMA. 2010;304(22). doi:10.1001/jama.2010.1817.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
June 02, 2025 - Observing Patient Care Rounds
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentinel events. Communication among disciplines can be improved if viewed through the eyes of an objective observer.
What are obser…
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psnet.ahrq.gov/issue/balancing-just-culture-regulatory-standards
December 13, 2023 - Commentary
Balancing just culture with regulatory standards.
Citation Text:
Gorzeman J. Balancing Just Culture with regulatory standards. Nurs Adm Q. 2008;32(4):308-11. doi:10.1097/01.NAQ.0000336728.72501.c6.
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psnet.ahrq.gov/issue/texting-debate-beneficial-means-communication-or-safety-and-security-risk
July 12, 2023 - Newspaper/Magazine Article
The texting debate: beneficial means of communication or safety and security risk?
Citation Text:
The texting debate: beneficial means of communication or safety and security risk? ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5.
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psnet.ahrq.gov/issue/minimize-medication-errors-urgent-care-clinics
March 29, 2023 - Newspaper/Magazine Article
Minimize medication errors in urgent care clinics.
Citation Text:
Minimize medication errors in urgent care clinics. Coffey SB. American Nurse Journal. Epub March 2, 2023.
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psnet.ahrq.gov/issue/implementing-rapid-response-team-practical-guide
July 14, 2010 - Commentary
Implementing a rapid response team: a practical guide.
Citation Text:
Implementing a rapid response team: a practical guide. Garretson S; Dip HE; Rauzi MB.
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psnet.ahrq.gov/issue/battling-hospital-acquired-infections
June 27, 2018 - Audiovisual
Battling hospital-acquired infections.
Citation Text:
Battling hospital-acquired infections. Gross T; Shannon R. NPR. January 9, 2008.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/055-guide-nursing-practice.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Decolonization Nursing Practice Guide
Use this guide to help ensure that all nursing practice procedures and leadership support are in place to actively support the decolonization intervention.
Engagement & Collaboration
Determine Which Patients Need Treatment
CHG Bath Docume…
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psnet.ahrq.gov/issue/quality-and-patient-safety-engaging-your-board-take-lead
April 21, 2015 - Newspaper/Magazine Article
Quality and patient safety. Engaging your board to take the lead.
Citation Text:
Bader BS. Quality and patient safety. Engaging your board to take the lead. Healthcare executive. 2006;21(2):64, 66-7.
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www.ahrq.gov/news/newsroom/case-studies/ktcquips52.html
October 01, 2014 - Nebraska Critical Access Hospitals Improve Safety With AHRQ TeamSTEPPS®
Search All Impact Case Studies
December 2010
The University of Nebraska Medical Center (UNMC) customized the coaching strategies used in the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) curriculum fo…
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psnet.ahrq.gov/issue/crime-workplace-part-1
September 11, 2024 - Commentary
Crime in the workplace, part 1.
Citation Text:
Pastorius D. Crime in the workplace, part 1. Nurs Manage. 2007;38(10):18, 20, 22, 24, 26-27.
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psnet.ahrq.gov/issue/dangers-diagnostic-overshadowing
October 26, 2022 - Commentary
Dangers of diagnostic overshadowing.
Citation Text:
Iezzoni LI. Dangers of Diagnostic Overshadowing. N Engl J Med. 2019;380(22):2092-2093. doi:10.1056/NEJMp1903078.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/communicating-decisions-one-pager.pdf
September 01, 2022 - Communicating With Patients and Families About Antibiotic Decisions
Communicating With Patients and Families
About Antibiotic Decisions
Patients want to feel
HEARD1-3
• Say: “What I am hearing you say is [repeat the main
concerns].”
• Sit at eye level with the patient.
• Nod your head to…
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psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
June 09, 2021 - Commentary
Human factors in patient safety as an innovation.
Citation Text:
Carayon P. Human factors in patient safety as an innovation. Appl Ergon. 2010;41(5):657-65. doi:10.1016/j.apergo.2009.12.011.
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psnet.ahrq.gov/issue/patient-safety-and-patient-error
June 02, 2010 - Commentary
Patient safety and patient error.
Citation Text:
Buetow S, Elwyn G. Patient safety and patient error. Lancet. 2007;369(9556):158-61.
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