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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/45561/psn-pdf
January 01, 2021 - Measuring patient safety: the Medicare Patient Safety
Monitoring System (past, present, and future).
November 2, 2016
Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring
System (Past, Present, and Future). J Patient Saf. 2021;17(3):e234-e240.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/44384/psn-pdf
August 12, 2015 - Effective followership: a standardized algorithm to
resolve clinical conflicts and improve teamwork.
August 12, 2015
Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical
conflicts and improve teamwork. J Healthc Risk Manag. 2015;35(1):21-30. doi:10.1002/jhrm.21174…
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psnet.ahrq.gov/node/43850/psn-pdf
March 11, 2015 - Practice and quality improvement: successful
implementation of TeamSTEPPS tools into an academic
interventional ultrasound practice.
March 11, 2015
Gupta RT, Sexton B, Milne J, et al. Practice and quality improvement: successful implementation of
TeamSTEPPS tools into an academic interventional ultrasound practice…
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psnet.ahrq.gov/node/41206/psn-pdf
March 14, 2012 - SBAR M&M: a feasible, reliable, and valid tool to assess
the quality of, surgical morbidity and mortality conference
presentations.
March 14, 2012
Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of,
surgical morbidity and mortality conference presentations.…
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psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
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psnet.ahrq.gov/node/46982/psn-pdf
June 13, 2018 - Advances in perioperative quality and safety.
June 13, 2018
Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Advances in perioperative quality and safety. Semin
Pediatr Surg. 2018;27(2):92-101. doi:10.1053/j.sempedsurg.2018.02.006.
https://psnet.ahrq.gov/issue/advances-perioperative-quality-and-safety
Clinical s…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/44130/psn-pdf
May 13, 2015 - Recent Evidence That Health IT Improves Patient Safety:
Issue Brief.
May 13, 2015
Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information
Technology; February 2015.
https://psnet.ahrq.gov/issue/recent-evidence-health-it-improves-patient-safety-issue-brief
Rapid implementatio…
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psnet.ahrq.gov/node/45822/psn-pdf
April 24, 2018 - Problems with health information technology and their
effects on care delivery and patient outcomes: a
systematic review.
April 24, 2018
Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care
delivery and patient outcomes: a systematic review. J Am Med Inform Assoc. 2017…
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psnet.ahrq.gov/node/43257/psn-pdf
August 14, 2014 - Barriers and success factors to the implementation of a
multi-site prospective adverse event surveillance system.
August 14, 2014
Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site
prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
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psnet.ahrq.gov/node/60190/psn-pdf
April 01, 2020 - Potentially Preventable Readmissions: Conceptual
Framework To Rethink the Role of Primary Care.
Executive Summary.
April 1, 2020
Maxwell J, Bourgoin A, Crandall J. Potentially Preventable Readmissions: Conceptual Framework To
Rethink The Role Of Primary Care. Executive Summary. Rockville, MD : Agency for Healthcar…
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psnet.ahrq.gov/node/46447/psn-pdf
September 27, 2017 - Creating highly reliable accountable care organizations.
September 27, 2017
Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev.
2016;73(6):660-672.
https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations
High reliability is a goal throughout …
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psnet.ahrq.gov/node/46172/psn-pdf
June 21, 2017 - Flying lessons for clinicians: developing system 2
practice.
June 21, 2017
Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air
Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003.
https://psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-p…
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psnet.ahrq.gov/node/43637/psn-pdf
April 25, 2016 - Lost in translation? Addressing barriers in the application
of industrial process improvement methodologies to
health care.
April 25, 2016
Gray D, Johnson KD, Watts B. Lost In Translation? Addressing Barriers in the Application of Industrial
Process Improvement Methodologies to Health Care. Jt Comm J Qual Patient …
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psnet.ahrq.gov/node/45339/psn-pdf
August 10, 2016 - Hospital at night: an organizational design that provides
safer care at night.
August 10, 2016
Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care
at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/45961/psn-pdf
June 23, 2017 - Burden of hospitalizations related to adverse drug events
in the USA: a retrospective analysis from large inpatient
database.
June 23, 2017
Poudel DR, Acharya P, Ghimire S, et al. Burden of hospitalizations related to adverse drug events in the
USA: a retrospective analysis from large inpatient database. Pharmacoe…
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psnet.ahrq.gov/node/844802/psn-pdf
September 18, 2019 - Using proactive risk assessment (HFMEA) to improve
patient safety and quality associated with intraocular lens
selection and implantation in cataract surgery.
September 18, 2019
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to
Improve Patient Safety and Quality Associ…