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psnet.ahrq.gov/node/39517/psn-pdf
May 25, 2010 - A prospective controlled trial of the effect of a multi-
faceted intervention on early recognition and intervention
in deteriorating hospital patients.
May 25, 2010
Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted
intervention on early recognition and inter…
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psnet.ahrq.gov/node/853962/psn-pdf
September 27, 2023 - Diagnosing fast and slow: cognitive bias in obstetrics.
September 27, 2023
Atallah F, Gomes C, Minkoff H. Diagnosing fast and slow: cognitive bias in obstetrics. Obstet Gynecol.
2023;142(3):727-732. doi:10.1097/aog.0000000000005303.
https://psnet.ahrq.gov/issue/diagnosing-fast-and-slow-cognitive-bias-obstetrics
Re…
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psnet.ahrq.gov/node/45264/psn-pdf
September 01, 2016 - Perceived factors associated with sustained improvement
following participation in a multicenter quality
improvement collaborative.
September 1, 2016
Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following
Participation in a Multicenter Quality Improvement Collaborative. Jt Co…
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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/46622/psn-pdf
December 06, 2017 - White paper on recommendation for systems-based
practice competency.
December 6, 2017
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force: White Paper on
Recommendation for Systems-Based Practice Competency. J Nurs Care Qual. 2017;32(4):354-358.
doi:10.1097/NCQ.0000000000000262.
https://psnet.a…
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psnet.ahrq.gov/node/73592/psn-pdf
August 11, 2021 - Using performance improvement to enhance time-out
compliance and prevent wrong-site surgery.
August 11, 2021
Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and
prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/aorn.13413.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45270/psn-pdf
June 29, 2016 - Using contemporary leadership skills in medication safety
programs.
June 29, 2016
Hertig JB, Hultgren KE, Weber RJ. Using Contemporary Leadership Skills in Medication Safety Programs.
Hosp Pharm. 2016;51(4):338-44. doi:10.1310/hpj5104-338.
https://psnet.ahrq.gov/issue/using-contemporary-leadership-skills-medicatio…
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psnet.ahrq.gov/node/46449/psn-pdf
September 27, 2017 - VA hospitals flooded with complaints about care.
September 27, 2017
Estes A. Boston Globe. September 16, 2017.
https://psnet.ahrq.gov/issue/va-hospitals-flooded-complaints-about-care
Psychological safety can empower staff to communicate concerns that affect patient safety. This
newspaper article reports on Veteran…
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psnet.ahrq.gov/node/43478/psn-pdf
August 27, 2014 - Is it time to move beyond errors in clinical reasoning and
discuss accuracy?
August 27, 2014
Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ
Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4.
https://psnet.ahrq.gov/issue/it-time-move-beyond-er…
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psnet.ahrq.gov/node/42308/psn-pdf
June 10, 2013 - Little shop of errors: an innovative simulation patient
safety workshop for community health care
professionals.
June 10, 2013
Tupper JB, Pearson KB, Meinersmann KM, et al. Little shop of errors: an innovative simulation patient
safety workshop for community health care professionals. J Contin Educ Nurs. 2013;44(6…
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psnet.ahrq.gov/node/44404/psn-pdf
August 26, 2015 - Nurse interrupted: development of a realistic medication
administration simulation for undergraduate nurses.
August 26, 2015
Hayes C, Power T, Davidson PM, et al. Nurse interrupted: Development of a realistic medication
administration simulation for undergraduate nurses. Nurse Educ Today. 2015;35(9):981-6.
doi:10.…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…
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psnet.ahrq.gov/node/40597/psn-pdf
August 10, 2011 - Improving follow-up of high-risk psychiatry outpatients at
resident year-end transfer.
August 10, 2011
Young JQ, Pringle Z, Wachter R. Improving follow-up of high-risk psychiatry outpatients at resident year-
end transfer. Jt Comm J Qual Patient Saf. 2011;37(7):300-308.
https://psnet.ahrq.gov/issue/improving-follo…
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psnet.ahrq.gov/node/36769/psn-pdf
June 15, 2011 - Using incident reporting to improve patient safety: a
conceptual model.
June 15, 2011
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J
Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-s…
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psnet.ahrq.gov/node/41457/psn-pdf
August 02, 2012 - The H-PEPSS: an instrument to measure health
professionals' perceptions of patient safety competence
at entry into practice.
August 2, 2012
Ginsburg LR, Castel E, Tregunno D, et al. The H-PEPSS: an instrument to measure health professionals'
perceptions of patient safety competence at entry into practice. BMJ Qual…
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psnet.ahrq.gov/node/43955/psn-pdf
December 04, 2016 - For Colorado mom, story of daughter's hospital death is
key to others' safety.
December 4, 2016
Daley J. Colorado Public Radio. February 17, 2015.
https://psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety
Patient and family stories of harm are increasingly promoted as a strategy to…
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psnet.ahrq.gov/node/72628/psn-pdf
January 13, 2021 - Awareness of human factors in the operating theatres
during the COVID-19 pandemic.
January 13, 2021
Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the
COVID-19 pandemic. J Perioper Pract. 2021;31(1-2):44-50. doi:10.1177/1750458920978858.
https://psnet.ahrq.gov/issue/awa…
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psnet.ahrq.gov/node/60034/psn-pdf
March 11, 2020 - Responding to unprofessional behavior by trainees - a
"just culture" framework.
March 11, 2020
Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just
Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591.
https://psnet.ahrq.gov/issue/resp…
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psnet.ahrq.gov/node/46697/psn-pdf
January 10, 2018 - Primary care providers' perspectives on errors of
omission.
January 10, 2018
Poghosyan L, Norful AA, Fleck E, et al. Primary Care Providers' Perspectives on Errors of Omission. J Am
Board Fam Med. 2017;30(6):733-742. doi:10.3122/jabfm.2017.06.170161.
https://psnet.ahrq.gov/issue/primary-care-providers-perspectives…
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effectivehealthcare.ahrq.gov/sites/default/files/cf_deliberativemethodswebinar_introduction.pdf
April 19, 2012 - Slide 1
Community Forum Community Forum
Agency for Healthcare Research and Quality
Community Forum
April 19, 2012
Using Deliberative Methods
to Engage the Public:
How to design and implement an effective
deliberative session
Community Forum Community Forum Community Forum
2
Purpose
…