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psnet.ahrq.gov/node/44939/psn-pdf
March 09, 2016 - Listening for What Matters: Avoiding Contextual Errors in
Health Care.
March 9, 2016
Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996.
https://psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care
This book discusses how physicians can reduce cont…
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psnet.ahrq.gov/node/40249/psn-pdf
June 20, 2011 - Nurses' perceptions of how rapid response teams affect
the nurse, team, and system.
June 20, 2011
Williams DJ, Newman A, Jones CB, et al. Nurses' perceptions of how rapid response teams affect the
nurse, team, and system. J Nurs Care Qual. 2011;26(3):265-72. doi:10.1097/NCQ.0b013e318209f135.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/39098/psn-pdf
November 11, 2009 - Building team and technical competency for obstetric
emergencies: the mobile obstetric emergencies simulator
(MOES) system.
November 11, 2009
Deering S, Rosen MA, Salas E, et al. Building team and technical competency for obstetric emergencies:
the mobile obstetric emergencies simulator (MOES) system. Simul Health…
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psnet.ahrq.gov/node/39966/psn-pdf
February 01, 2011 - Journey to no preventable risk: The Baylor Health Care
System patient safety experience.
February 1, 2011
Kennerly DA, Richter KM, Good V, et al. Journey to no preventable risk: the Baylor Health Care System
patient safety experience. Am J Med Qual. 2011;26(1):43-52. doi:10.1177/1062860610374645.
https://psnet.ahr…
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psnet.ahrq.gov/node/47821/psn-pdf
May 22, 2019 - Patient Safety.
May 22, 2019
National Pharmacy Association; NPA.
https://psnet.ahrq.gov/issue/patient-safety-15
This website for independent community pharmacy owners across the United Kingdom features both free
and members-only guidance, reporting platforms, and document templates to support patient safety. It
i…
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psnet.ahrq.gov/node/74764/psn-pdf
February 09, 2022 - ESPEN guideline on hospital nutrition.
February 9, 2022
Thibault R, Abbasoglu O, Ioannou E, et al. ESPEN guideline on hospital nutrition. Clin Nutr.
2021;40(12):5684-5709. doi:10.1016/j.clnu.2021.09.039.
https://psnet.ahrq.gov/issue/espen-guideline-hospital-nutrition
Mistakes in hospital dietary services can contr…
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psnet.ahrq.gov/node/44452/psn-pdf
September 04, 2016 - Reflecting on diagnostic errors: taking a second look is
not enough.
September 4, 2016
Monteiro SD, Sherbino J, Patel A, et al. Reflecting on Diagnostic Errors: Taking a Second Look is Not
Enough. J Gen Intern Med. 2015;30(9):1270-4. doi:10.1007/s11606-015-3369-4.
https://psnet.ahrq.gov/issue/reflecting-diagnostic…
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psnet.ahrq.gov/node/46875/psn-pdf
March 07, 2018 - Improving medication-related clinical decision support.
March 7, 2018
Tolley CL, Slight SP, Husband AK, et al. Improving medication-related clinical decision support. Am J
Health Syst Pharm. 2018;75(4):239-246. doi:10.2146/ajhp160830.
https://psnet.ahrq.gov/issue/improving-medication-related-clinical-decision-suppo…
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psnet.ahrq.gov/node/38361/psn-pdf
January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue,
improve patient safety.
January 31, 2011
Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA.
2009;301(3):259-61. doi:10.1001/jama.2008.940.
https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…
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psnet.ahrq.gov/node/38592/psn-pdf
April 29, 2009 - The teaching of a structured tool improves the clarity and
content of interprofessional clinical communication.
April 29, 2009
Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of
interprofessional clinical communication. Qual Saf Health Care. 2009;18(2):137-40.
…
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psnet.ahrq.gov/node/841197/psn-pdf
December 07, 2022 - Does malpractice liability promote patient safety? A
methodological excursion.
December 7, 2022
Saks MJ, Landsman S. Jurimetrics. 2022;62:397-419.
https://psnet.ahrq.gov/issue/does-malpractice-liability-promote-patient-safety-methodological-excursion
Malpractice liability is an unconfirmed driver for safety. This …
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psnet.ahrq.gov/node/46593/psn-pdf
November 08, 2017 - Unreadable barcodes and multiple barcodes on packages
can lead to errors.
November 8, 2017
ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3.
https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors
Barcodes can both enhance and degrade the medication …
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psnet.ahrq.gov/node/44468/psn-pdf
September 23, 2015 - LINNEAUS Collaboration on Patient Safety in Primary
Care.
September 23, 2015
Eur J Gen Pract. 2015;(suppl 21):1-77.
https://psnet.ahrq.gov/issue/linneaus-collaboration-patient-safety-primary-care
Collaborative efforts provide learning opportunities for groups that seek to develop widely implementable
improvements…
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psnet.ahrq.gov/node/41929/psn-pdf
January 09, 2013 - Quality improvement: Universal Protocol use in office-
based gastrointestinal procedure units.
January 9, 2013
Hardee LK. Quality improvement: universal protocol use in office-based gastrointestinal procedure units.
Gastroenterol Nurs. 2012;35(6):380-2. doi:10.1097/SGA.0b013e3182747956.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/37286/psn-pdf
December 23, 2011 - Different roles, same goal: risk and quality management
partnering for patient safety. By the ASHRM Monographs
Task Force.
December 23, 2011
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient
Safety. By The Ashrm Monographs Task Force.; 2007:17-23, 25. doi:10.1002/jhr…
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psnet.ahrq.gov/node/46557/psn-pdf
November 22, 2017 - Safe handover.
November 22, 2017
Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328.
https://psnet.ahrq.gov/issue/safe-handover
Patient handovers between clinical teams are a common point of information exchange that can be
challenging to perform due to interruptions, produ…
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psnet.ahrq.gov/node/43530/psn-pdf
April 02, 2015 - Patient participation in patient safety and nursing
input—a systematic review.
April 2, 2015
Vaismoradi M, Jordan S, Kangasniemi M. Patient participation in patient safety and nursing input - a
systematic review. J Clin Nurs. 2015;24(5-6):627-39. doi:10.1111/jocn.12664.
https://psnet.ahrq.gov/issue/patient-partici…
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psnet.ahrq.gov/node/37272/psn-pdf
December 23, 2011 - Communication techniques for patients with low health
literacy: a survey of physicians, nurses, and pharmacists.
December 23, 2011
Schwartzberg JG, Cowett A, VanGeest J, et al. Communication techniques for patients with low health
literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31…
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psnet.ahrq.gov/node/862621/psn-pdf
February 14, 2024 - Toward the eradication of medical diagnostic errors.
February 14, 2024
Topol EJ. Toward the eradication of medical diagnostic errors. Science. 2024;383(6681):eadn9602.
doi:10.1126/science.adn9602.
https://psnet.ahrq.gov/issue/toward-eradication-medical-diagnostic-errors
Artificial intelligence (AI) is being touted…
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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…