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psnet.ahrq.gov/node/72468/psn-pdf
November 18, 2020 - Development of rapid response capabilities in a large
COVID-19 alternate care site using Failure Modes and
Effect Analysis with in situ simulation.
November 18, 2020
Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19
alternate care site using Failure Modes and Eff…
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psnet.ahrq.gov/node/45277/psn-pdf
July 01, 2017 - Cultural transformation after implementation of crew
resource management: is it really possible?
July 1, 2017
Hefner JL, Hilligoss B, Knupp A, et al. Cultural Transformation After Implementation of Crew Resource
Management: Is It Really Possible? Am J Med Qual. 2017;32(4):384-390. doi:10.1177/1062860616655424.
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psnet.ahrq.gov/node/865922/psn-pdf
May 22, 2024 - Pharmacy-driven performance improvement initiative to
increase compliance with intravenous smart pump drug
error reduction systems at a large urban academic
medical center.
May 22, 2024
Abboudi E, Baron SW, Goriacko P, et al. Pharmacy-driven performance improvement initiative to increase
compliance with intraveno…
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psnet.ahrq.gov/node/74257/psn-pdf
January 19, 2022 - Early prescribing outcomes after exporting the EQUIPPED
medication safety improvement programme.
January 19, 2022
Vaughan CP, Hwang U, Vandenberg AE, et al. Early prescribing outcomes after exporting the EQUIPPED
medication safety improvement programme. BMJ Open Qual. 2021;10(4):e001369. doi:10.1136/bmjoq-
2021-00…
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psnet.ahrq.gov/node/43193/psn-pdf
June 17, 2014 - Risks in the implementation and use of smart pumps in a
pediatric intensive care unit: application of the failure
mode and effects analysis.
June 17, 2014
Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of
smart pumps in a pediatric intensive care unit: applicati…
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psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…
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psnet.ahrq.gov/node/863748/psn-pdf
March 06, 2024 - Scaling the EQUIPPED medication safety program:
traditional and hub-and-spoke implementation models.
March 6, 2024
Vandenberg AE, Hwang U, Das S, et al. Scaling the EQUIPPED medication safety program: traditional and
hub?and?spoke implementation models. J Am Geriatr Soc. 2024;72(7):2184-2194. doi:10.1111/jgs.18746.…
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psnet.ahrq.gov/node/852444/psn-pdf
August 16, 2023 - Comparing rates of adverse events detected in incident
reporting and the Global Trigger Tool: a systematic
review.
August 16, 2023
Hibbert PD, Molloy CJ, Schultz TJ, et al. Comparing rates of adverse events detected in incident reporting
and the Global Trigger Tool: a systematic review. Int J Qual Health Care. 202…
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psnet.ahrq.gov/node/37260/psn-pdf
January 02, 2017 - A visual medication schedule to improve anticoagulation
control: a randomized, controlled trial.
January 2, 2017
Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a
randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;33(10):625-35.
https://psnet.ahr…
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psnet.ahrq.gov/node/46007/psn-pdf
July 09, 2018 - A family-centered rounds checklist, family engagement,
and patient safety: a randomized trial.
July 9, 2018
Cox E, Jacobsohn GC, Rajamanickam VP, et al. A Family-Centered Rounds Checklist, Family
Engagement, and Patient Safety: A Randomized Trial. Pediatrics. 2017;139(5). doi:10.1542/peds.2016-
1688.
https://psne…
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psnet.ahrq.gov/node/44819/psn-pdf
June 21, 2016 - Opioid prescribing after nonfatal overdose and
association with repeated overdose: a cohort study.
June 21, 2016
Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid Prescribing After Nonfatal Overdose and Association
With Repeated Overdose: A Cohort Study. Ann Inter Med. 2016;164(1):1-9. doi:10.7326/M15-0038.
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - Decreasing handoff-related care failures in children's
hospitals.
August 13, 2014
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's
hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844.
https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Patient groups, clinicians and healthcare professionals
agree—all test results need to be seen, understood and
followed up.
December 19, 2018
Dahm MR, Georgiou A, Herkes R, et al. Patient groups, clinicians and healthcare professionals agree - all
test results need to be seen, understood and followed up. Diagnosis…
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psnet.ahrq.gov/node/45907/psn-pdf
December 22, 2017 - Primary care collaboration to improve diagnosis and
screening for colorectal cancer.
December 22, 2017
Schiff G, Bearden T, Hunt LS, et al. Primary Care Collaboration to Improve Diagnosis and Screening for
Colorectal Cancer. Jt Comm J Qual Patient Saf. 2017;43(7):338-350. doi:10.1016/j.jcjq.2017.03.004.
https://ps…
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psnet.ahrq.gov/node/44963/psn-pdf
January 23, 2017 - The frequency of intravenous medication administration
errors related to smart infusion pumps: a multihospital
observational study.
January 23, 2017
Schnock KO, Dykes PC, Albert J, et al. The frequency of intravenous medication administration errors
related to smart infusion pumps: a multihospital observational st…
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psnet.ahrq.gov/node/866910/psn-pdf
October 09, 2024 - From theory to policy in resilient health care: policy
recommendations and lessons learnt from the Resilience
in Healthcare Research Program.
October 9, 2024
Wiig S, Lyng HB, Guise V, et al. From theory to policy in resilient health care: policy recommendations and
lessons learnt from the Resilience in Healthcare …
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psnet.ahrq.gov/node/44044/psn-pdf
June 21, 2015 - A collaborative learning network approach to
improvement: the CUSP learning network.
June 21, 2015
Weaver SJ, Lofthus J, Sawyer M, et al. A Collaborative Learning Network Approach to Improvement: The
CUSP Learning Network. Jt Comm J Qual Patient Saf. 2015;41(4):147-159.
https://psnet.ahrq.gov/issue/collaborative-l…
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psnet.ahrq.gov/node/46652/psn-pdf
July 14, 2018 - The effects of crew resource management on teamwork
and safety climate at Veterans Health Administration
facilities.
July 14, 2018
Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource management on teamwork and
safety climate at Veterans Health Administration facilities. J Healthc Risk Manag. 2018;…
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psnet.ahrq.gov/node/41942/psn-pdf
July 24, 2017 - Improving situation awareness to reduce unrecognized
clinical deterioration and serious safety events.
July 24, 2017
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical
deterioration and serious safety events. Pediatrics. 2013;131(1):e298-308. doi:10.1542/peds.2012-…
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psnet.ahrq.gov/node/44609/psn-pdf
June 21, 2016 - The missing evidence: a systematic review of patients'
experiences of adverse events in health care.
June 21, 2016
Harrison R, Walton M, Manias E, et al. The missing evidence: a systematic review of patients' experiences
of adverse events in health care. Int J Qual Health Care. 2015;27(6):424-42. doi:10.1093/intqhc…