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psnet.ahrq.gov/node/45693/psn-pdf
February 22, 2017 - Meta-analyses of the effects of standardized handoff
protocols on patient, provider, and organizational
outcomes.
February 22, 2017
Keebler JR, Lazzara EH, Patzer BS, et al. Meta-Analyses of the Effects of Standardized Handoff Protocols
on Patient, Provider, and Organizational Outcomes. Hum Factors. 2016;58(8):118…
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psnet.ahrq.gov/node/45465/psn-pdf
September 07, 2016 - Improving patient safety culture in primary care: a
systematic review.
September 7, 2016
Verbakel NJ, Langelaan M, Verheij TJM, et al. Improving Patient Safety Culture in Primary Care: A
Systematic Review. J Patient Saf. 2016;12(3):152-8. doi:10.1097/PTS.0000000000000075.
https://psnet.ahrq.gov/issue/improving-pat…
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psnet.ahrq.gov/node/836792/psn-pdf
March 23, 2022 - Remote patient monitoring during COVID-19: an
unexpected patient safety benefit.
March 23, 2022
Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient
safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040.
https://psnet.ahrq.gov/issue/remote-patient-mo…
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psnet.ahrq.gov/node/42915/psn-pdf
January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign:
a statewide collaborative.
February 5, 2014
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively:
A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553-
7250(14)40026-6.
…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/45657/psn-pdf
March 08, 2017 - The causes of errors in clinical reasoning: cognitive
biases, knowledge deficits, and dual process thinking.
March 8, 2017
Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases,
Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30.
doi:10.1097/…
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psnet.ahrq.gov/node/849615/psn-pdf
May 31, 2023 - Clinical Investigation Booking Systems Failures: Written
Communications in Community Languages.
May 31, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-
community-languages
Gaps in patient…
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psnet.ahrq.gov/node/866399/psn-pdf
July 31, 2024 - Typology of solutions addressing diagnostic disparities:
gaps and opportunities.
July 31, 2024
Dukhanin V, Wiegand AA, Sheikh T, et al. Typology of solutions addressing diagnostic disparities: gaps
and opportunities. Diagnosis (Berl). 2024;11(4):389-399. doi:10.1515/dx-2024-0026.
https://psnet.ahrq.gov/issue/typol…
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psnet.ahrq.gov/node/47800/psn-pdf
June 26, 2019 - Error and Uncertainty in Diagnostic Radiology.
June 26, 2019
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to
uncer…
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psnet.ahrq.gov/node/44795/psn-pdf
June 29, 2016 - Human factors in healthcare: welcome progress, but still
scratching the surface.
June 29, 2016
Waterson P, Catchpole K. Human factors in healthcare: welcome progress, but still scratching the surface.
BMJ Qual Saf. 2016;25(7):480-4. doi:10.1136/bmjqs-2015-005074.
https://psnet.ahrq.gov/issue/human-factors-healthca…
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psnet.ahrq.gov/node/46938/psn-pdf
April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse
practitioners.
April 25, 2018
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ.
2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…
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psnet.ahrq.gov/node/47737/psn-pdf
March 06, 2019 - Quality improvement and safety in pediatric emergency
medicine.
March 6, 2019
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine.
Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…
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psnet.ahrq.gov/node/44146/psn-pdf
June 03, 2015 - Transforming communication and safety culture in
intrapartum care: a multi-organization blueprint.
June 3, 2015
Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum
care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049-55.
doi:10.1097/AOG.000000000000…
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psnet.ahrq.gov/node/44647/psn-pdf
November 18, 2015 - An organisation without a memory: a qualitative study of
hospital staff perceptions on reporting and organisational
learning for patient safety.
November 18, 2015
Sujan M. An organisation without a memory: A qualitative study of hospital staff perceptions on reporting
and organisational learning for patient safety…
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psnet.ahrq.gov/node/43645/psn-pdf
November 12, 2014 - Health IT and Clinical Decision Support Systems.
November 12, 2014
Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
https://psnet.ahrq.gov/issue/health-it-and-clinical-decision-support-systems
A universal agreement on how to calculate the return on investment for health information technology (IT)
and…
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psnet.ahrq.gov/node/866824/psn-pdf
September 25, 2024 - 'Failing wisely' can promote a safer healthcare system.
September 25, 2024
Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today.
September 17, 2024;
https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
The ability to learn-by-doing in an enviro…
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psnet.ahrq.gov/node/44853/psn-pdf
February 03, 2016 - Aviation and healthcare: a comparative review with
implications for patient safety.
February 3, 2016
Kapur N, Parand A, Soukup T, et al. Aviation and healthcare: a comparative review with implications for
patient safety. JRSM Open. 2016;7(1):2054270415616548. doi:10.1177/2054270415616548.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46548/psn-pdf
April 16, 2018 - Nurses' communication of safety events to nursing home
residents and families.
April 16, 2018
Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home
Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45812/psn-pdf
June 22, 2017 - A primer on PDSA: executing plan–do–study–act cycles
in practice, not just in name.
June 22, 2017
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name.
BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
https://psnet.ahrq.gov/issue/primer-pdsa-execu…
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psnet.ahrq.gov/node/46784/psn-pdf
January 11, 2023 - Patient Safety Learning Laboratories: Advancing Patient
Safety through Design, Systems Engineering, and Health
Services Research (R18 Clinical Trial Optional).
January 11, 2023
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
https://psnet.ahrq.gov/issue/patient-safety-learning-laboratories-ad…