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psnet.ahrq.gov/node/43062/psn-pdf
September 04, 2016 - The relationship between patient safety culture and
patient outcomes: a systematic review.
September 4, 2016
DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic
Review. J Patient Saf. 2015;11(3):135-42. doi:10.1097/PTS.0000000000000058.
https://psnet.ahrq.gov/issue/relat…
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psnet.ahrq.gov/node/46192/psn-pdf
June 07, 2017 - Investigating the causes of adverse events.
June 7, 2017
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac
Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001.
https://psnet.ahrq.gov/issue/investigating-causes-adverse-events
Incident analysis enab…
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psnet.ahrq.gov/node/46810/psn-pdf
April 18, 2018 - Unintended doses in radiotherapy—over, under and
outside?
April 18, 2018
Eaton DJ, Byrne JP, Cosgrove VP, et al. Unintended doses in radiotherapy-over, under and outside? Br J
Radiol. 2018;91(1084):20170863. doi:10.1259/bjr.20170863.
https://psnet.ahrq.gov/issue/unintended-doses-radiotherapy-over-under-and-outside…
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psnet.ahrq.gov/node/44090/psn-pdf
November 21, 2016 - Insensible losses: when the medical community forgets
the family.
November 21, 2016
Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood).
2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536.
https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…
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psnet.ahrq.gov/node/40670/psn-pdf
August 03, 2011 - ED revamp: team approach to care reduces errors, boosts
patient and clinician satisfaction.
August 3, 2011
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. ED
management : the monthly update on emergency department management. 2011;23(7):78-80.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…
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psnet.ahrq.gov/node/47003/psn-pdf
July 18, 2018 - Impact of an antiretroviral stewardship strategy on
medication error rates.
July 18, 2018
Shea KM, Hobbs AL, Shumake JD, et al. Impact of an antiretroviral stewardship strategy on medication
error rates. Am J Health Syst Pharm. 2018;75(12):876-885. doi:10.2146/ajhp170420.
https://psnet.ahrq.gov/issue/impact-antire…
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psnet.ahrq.gov/node/41771/psn-pdf
March 20, 2018 - Improving Patient Safety Systems for Patients With
Limited English Proficiency: A Guide For Hospitals.
March 20, 2018
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-
0041.
https://psnet.ahrq.gov/issue/improving-patient-safety-systems-patients-limited-english-prof…
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psnet.ahrq.gov/node/43961/psn-pdf
August 02, 2015 - Reducing inappropriate polypharmacy: the process of
deprescribing.
August 2, 2015
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing.
JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324.
https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…
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psnet.ahrq.gov/node/44332/psn-pdf
July 29, 2015 - Health IT Safety Center Roadmap.
July 29, 2015
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology;
July 2015.
https://psnet.ahrq.gov/issue/health-it-safety-center-roadmap
The Institute of Medicine called for enhanced transparency in the reporting of health IT sa…
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psnet.ahrq.gov/node/36884/psn-pdf
May 27, 2011 - Evaluation of outpatient computerized physician
medication order entry systems: a systematic review.
May 27, 2011
Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order
entry systems: a systematic review. J Am Med Inform Assoc. 2007;14(4):400-6.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/39374/psn-pdf
March 17, 2010 - Bridging the gap: leveraging business intelligence tools
in support of patient safety and financial effectiveness.
March 17, 2010
Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in
support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…
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psnet.ahrq.gov/node/38644/psn-pdf
May 20, 2009 - A quality initiative to decrease pathology specimen-
labeling errors using radiofrequency identification in a
high-volume endoscopy center.
May 20, 2009
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling
errors using radiofrequency identification in a high-volume en…
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psnet.ahrq.gov/node/44270/psn-pdf
July 01, 2015 - Improving Patient Safety Culture Through Teamwork and
Communication: TeamSTEPPS.
July 1, 2015
Chicago, IL: Health Research & Educational Trust; June 2015.
https://psnet.ahrq.gov/issue/improving-patient-safety-culture-through-teamwork-and-communication-
teamstepps
This guide draws from the experience of organizati…
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psnet.ahrq.gov/node/46414/psn-pdf
January 10, 2018 - Leveraging the electronic health record to improve quality
and safety in rheumatology.
January 10, 2018
Schmajuk G, Yazdany J. Leveraging the electronic health record to improve quality and safety in
rheumatology. Rheumatol Int. 2017;37(10):1603-1610. doi:10.1007/s00296-017-3804-4.
https://psnet.ahrq.gov/issue/lev…
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psnet.ahrq.gov/node/44200/psn-pdf
February 18, 2019 - Structured handover in general surgery: an audit of
current practice.
February 18, 2019
Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J
Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201.
https://psnet.ahrq.gov/issue/structured-handover-general-…
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - root-cause-analysis
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care
teams, enhancing
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management,
which