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psnet.ahrq.gov/node/73968/psn-pdf
October 13, 2021 - Institution of just culture physician peer review in an
academic medical center.
October 13, 2021
Volkar JK, Phrampus P, English D, et al. Institution of just culture physician peer review in an academic
medical center. J Patient Saf. 2021;17(7):e689-e693. doi:10.1097/pts.0000000000000449.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/37929/psn-pdf
February 18, 2011 - Impact of duty hour regulations on medical students'
education: views of key clinical faculty.
February 18, 2011
Reed DA, Levine RB, Miller RG, et al. Impact of duty hour regulations on medical students' education:
views of key clinical faculty. J Gen Intern Med. 2008;23(7):1084-9. doi:10.1007/s11606-008-0532-1.
h…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/44423/psn-pdf
January 22, 2016 - Resident supervision and patient safety: do different
levels of resident supervision affect the rate of morbidity
and mortality cases?
January 22, 2016
Van Leer PE, Lavine EK, Rabrich JS, et al. Resident Supervision and Patient Safety: Do Different Levels of
Resident Supervision Affect the Rate of Morbidity and Mo…
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psnet.ahrq.gov/node/60155/psn-pdf
March 25, 2020 - Analysis of patient-physician concordance in the
understanding of chemotherapy treatment plans among
patients with cancer.
March 25, 2020
Almalki H, Absi A, Alghamdi A, et al. Analysis of patient-physician concordance in the understanding of
chemotherapy treatment plans among patients with cancer. JAMA Netw Open. …
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psnet.ahrq.gov/node/72478/psn-pdf
November 18, 2020 - The impact of the use of employee functional flexibility on
patient safety.
November 18, 2020
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient
safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
https://psnet.ahrq.gov/issue/impact-use-empl…
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psnet.ahrq.gov/node/866325/psn-pdf
July 17, 2024 - "What do health inequities have to do with anything?".
July 17, 2024
Kalinowski J. "What do health inequities have to do with anything?". N Engl J Med. 2024;390(23):e61.
doi:10.1056/nejmpv2404787.
https://psnet.ahrq.gov/issue/what-do-health-inequities-have-do-anything
Personal stories of poor care can catalyze the…
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psnet.ahrq.gov/node/45456/psn-pdf
October 27, 2016 - On the relationship between safety climate and
occupational burnout in healthcare organizations.
October 27, 2016
Zarei E, Khakzad N, Reniers G, et al. On the relationship between safety climate and occupational burnout
in healthcare organizations. Saf Sci. 2016;89:1-10. doi:10.1016/j.ssci.2016.05.011.
https://psn…
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psnet.ahrq.gov/node/47020/psn-pdf
January 16, 2019 - Unintended harm associated with the Hospital
Readmissions Reduction Program.
January 16, 2019
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA.
2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
https://psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmiss…
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.pdf
March 01, 2017 - Remember T.E.A.M.S. to Improve Safety Culture
T
E
A
M
S
Team
Formation
Excellent
Communication
Assess
What’s
Working
Meet
Monthly
Sustain
Efforts
The most effective teams are diverse. Make sure
your team includes people of differing perspectives
and roles.
Communication should be effective. Commu…
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psnet.ahrq.gov/node/41887/psn-pdf
January 07, 2015 - Bariatric surgery with operating room teams that stayed
fixed during the day: a multicenter study analyzing the
effects on patient outcomes, teamwork and safety
climate, and procedure duration.
January 7, 2015
Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating room teams that stayed fixed duri…
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psnet.ahrq.gov/node/44922/psn-pdf
March 01, 2017 - Mobilising a team for the WHO Surgical Safety Checklist:
a qualitative video study.
March 1, 2017
Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ
Qual Saf. 2017;26(3):177-188. doi:10.1136/bmjqs-2015-004887.
https://psnet.ahrq.gov/issue/mobilising-team-who-sur…
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psnet.ahrq.gov/node/50938/psn-pdf
February 26, 2020 - Risks and medication errors analysis to evaluate the
impact of a chemotherapy compounding workflow
management system on cancer patients' safety.
February 26, 2020
Marzal-Alfaro MB, Rodriguez-Gonzalez CG, Escudero-Vilaplana V, et al. Risks and medication errors
analysis to evaluate the impact of a chemotherapy comp…
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psnet.ahrq.gov/node/36612/psn-pdf
January 14, 2011 - Does the patient's payer matter in hospital patient
safety?: a study of urban hospitals.
January 14, 2011
Clement JP, Lindrooth R, Chukmaitov AS, et al. Does the patient's payer matter in hospital patient safety?:
a study of urban hospitals. Med Care. 2007;45(2):131-8.
https://psnet.ahrq.gov/issue/does-patients-pa…
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psnet.ahrq.gov/node/860717/psn-pdf
January 17, 2024 - A combined assessment tool of teamwork,
communication, and workload in hospital procedural
units.
January 17, 2024
Weaver BW, Murphy DJ. A combined assessment tool of teamwork, communication, and workload in
hospital procedural units. Jt Comm J Qual Patient Saf. 2024;50(3):219-227. doi:10.1016/j.jcjq.2023.10.014.
…
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psnet.ahrq.gov/node/866162/psn-pdf
June 19, 2024 - Surgeon and surgical trainee experiences after adverse
patient events.
June 19, 2024
Ginzberg SP, Gasior JA, Passman JE, et al. Surgeon and surgical trainee experiences after adverse
patient events. JAMA Netw Open. 2024;7(6):e2414329. doi:10.1001/jamanetworkopen.2024.14329.
https://psnet.ahrq.gov/issue/surgeon-and…
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www.ahrq.gov/patient-safety/reports/engage/strategies.html
April 01, 2018 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Evidence-Based Strategies To Engage Patients and Families To Improve Patient Safety
This Guide is composed of four evidence-based strategies that promote meaningful engagement with patients and families in ways that …
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www.ahrq.gov/ncepcr/research/care-coordination/index.html
September 01, 2022 - Care Coordination
Care coordination, a key element for delivery of quality primary care, involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs an…
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digital.ahrq.gov/ahrq-funded-projects/improving-diabetes-and-depression-self-management-adaptive-mobile-messaging/citation/effectiveness
January 01, 2024 - Effectiveness of a digital health intervention leveraging reinforcement learning: Results from the Diabetes and Mental Health Adaptive Notification Tracking and Evaluation (DIAMANTE) randomized clinical trial.
Citation
Aguilera A, Arévalo Avalos M, Xu J, Chakraborty B, Figueroa C, Garcia F, Rosales K,…