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psnet.ahrq.gov/node/47810/psn-pdf
March 13, 2019 - Debriefing in the OR: a quality improvement project.
March 13, 2019
Finch EP, Langston M, Erickson D, et al. Debriefing in the OR: A Quality Improvement Project. AORN J.
2019;109(3):336-344. doi:10.1002/aorn.12616.
https://psnet.ahrq.gov/issue/debriefing-or-quality-improvement-project
Debriefing has emerged as a s…
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psnet.ahrq.gov/node/46148/psn-pdf
May 31, 2017 - Implementation of a structured hospital-wide morbidity
and mortality rounds model.
May 31, 2017
Kwok ESH, Calder LA, Barlow-Krelina E, et al. Implementation of a structured hospital-wide morbidity and
mortality rounds model. BMJ Qual Saf. 2017;26(6):439-448. doi:10.1136/bmjqs-2016-005459.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46725/psn-pdf
April 11, 2018 - Are we missing the near misses in the OR?
Underreporting of safety incidents in pediatric surgery.
April 11, 2018
Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?-
underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342.
doi:10.1016/j.jss.2017.08.…
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psnet.ahrq.gov/node/866112/psn-pdf
June 12, 2024 - Automated dispensing cabinets and their impact on the
rate of omitted and delayed doses: a systematic review.
June 12, 2024
Jeffrey E, Dalby M, Walsh Á, et al. Automated dispensing cabinets and their impact on the rate of omitted
and delayed doses: a systematic review. Explor Res Clin Soc Pharm. 2024;14:100451.
do…
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psnet.ahrq.gov/node/46138/psn-pdf
May 31, 2017 - An innovative collaborative model of care for
undiagnosed complex medical conditions.
May 31, 2017
Nageswaran S, Donoghue N, Mitchell A, et al. An Innovative Collaborative Model of Care for Undiagnosed
Complex Medical Conditions. Pediatrics. 2017;139(5):e20163373. doi:10.1542/peds.2016-3373.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47775/psn-pdf
April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic
management teams.
April 3, 2019
Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic
Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121.
https://psnet.ahrq.gov/issue/reducing-diagnostic-error…
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psnet.ahrq.gov/node/42085/psn-pdf
March 13, 2013 - In-facility delirium programs as a patient safety strategy:
a systematic review.
March 13, 2013
Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158-5-201303051-00003.
https://psnet.ah…
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psnet.ahrq.gov/node/44749/psn-pdf
December 27, 2018 - Southern Baptist Hospital of Florida v. Charles.
December 27, 2018
Fla Ct App, 1st Dist. October 28, 2015.
https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles
The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event
reports voluntarily submitted to pa…
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psnet.ahrq.gov/node/48159/psn-pdf
July 31, 2019 - Fatigue in radiology: a fertile area for future research.
July 31, 2019
Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol.
2019;92(1099):20190043. doi:10.1259/bjr.20190043.
https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research
Physician fatigu…
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psnet.ahrq.gov/node/44787/psn-pdf
January 20, 2016 - Medication errors involving overrides of healthcare
technology.
January 20, 2016
Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148.
https://psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology
Users often bypass alerts meant to enhance safety of medication ordering and d…
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psnet.ahrq.gov/node/44890/psn-pdf
July 11, 2017 - The frequency of inappropriate nonformulary medication
alert overrides in the inpatient setting.
July 11, 2017
Her QL, Amato MG, Seger DL, et al. The frequency of inappropriate nonformulary medication alert
overrides in the inpatient setting. J Am Med Inform Assoc. 2016;23(5):924-33. doi:10.1093/jamia/ocv181.
http…
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psnet.ahrq.gov/node/39286/psn-pdf
February 10, 2010 - Video registration of trauma team performance in the
emergency department: the results of a 2-year analysis in
a Level 1 trauma center.
February 10, 2010
Lubbert PHW, Kaasschieter EG, Hoorntje LE, et al. Video registration of trauma team performance in the
emergency department: the results of a 2-year analysis in …
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psnet.ahrq.gov/node/41459/psn-pdf
August 02, 2012 - The use of simulation in healthcare: from systems issues,
to team building, to task training, to education and high
stakes examinations.
August 2, 2012
Orledge J, Phillips WJ, Murray B, et al. The use of simulation in healthcare: from systems issues, to team
building, to task training, to education and high stakes…
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psnet.ahrq.gov/node/46476/psn-pdf
October 04, 2017 - The effectiveness of nurse education and training for
clinical alarm response and management: a systematic
review.
October 4, 2017
Yue L, Plummer V, Cross W. The effectiveness of nurse education and training for clinical alarm response
and management: a systematic review. J Clin Nurs. 2017;26(17-18):2511-2526. doi…
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psnet.ahrq.gov/node/47641/psn-pdf
March 20, 2019 - Guided reflection interventions show no effect on
diagnostic accuracy in medical students.
March 20, 2019
Lambe KA, Hevey D, Kelly BD. Guided Reflection Interventions Show No Effect on Diagnostic Accuracy in
Medical Students. Front Psychol. 2018;9:2297. doi:10.3389/fpsyg.2018.02297.
https://psnet.ahrq.gov/issue/gu…
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psnet.ahrq.gov/node/48151/psn-pdf
August 07, 2019 - Dental patient safety in the military health system: joining
medicine in the journey to high reliability.
August 7, 2019
Stahl JM, Mack K, Cebula S, et al. Dental Patient Safety in the Military Health System: Joining Medicine in
the Journey to High Reliability. Mil Med. 2019. doi:10.1093/milmed/usz154.
https://psn…
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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