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psnet.ahrq.gov/node/47467/psn-pdf
January 21, 2019 - Application of electronic trigger tools to identify targets
for improving diagnostic safety.
January 21, 2019
Murphy DR, Meyer AN, Sittig DF, et al. Application of electronic trigger tools to identify targets for improving
diagnostic safety. BMJ Qual Saf. 2019;28(2):151-159. doi:10.1136/bmjqs-2018-008086.
https://…
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psnet.ahrq.gov/node/39338/psn-pdf
April 30, 2014 - The effect of multidisciplinary care teams on intensive
care unit mortality.
April 30, 2014
Kim MM, Barnato AE, Angus DC, et al. The effect of multidisciplinary care teams on intensive care unit
mortality. Arch Intern Med. 2010;170(4):369-76. doi:10.1001/archinternmed.2009.521.
https://psnet.ahrq.gov/issue/effect-…
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psnet.ahrq.gov/node/866906/psn-pdf
October 09, 2024 - Potential harms resulting from patient–clinician real-time
clinical encounters using video-based telehealth: a
making healthcare safer rapid evidence review.
October 9, 2024
Rosen MA, Stewart CM, Kharrazi H, et al. Potential harms resulting from patient–clinician real-time clinical
encounters using video-based tel…
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psnet.ahrq.gov/node/851053/psn-pdf
June 28, 2023 - In situ simulation as a quality improvement tool to identify
and mitigate latent safety threats for emergency
department SARS-CoV-2 airway management: a multi-
institutional initiative.
June 28, 2023
Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improvement tool to identify and
mitigate…
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psnet.ahrq.gov/node/45562/psn-pdf
October 12, 2016 - Characterising the nature of primary care patient safety
incident reports in the England and Wales National
Reporting and Learning System: a mixed-methods
agenda-setting study for general practice.
October 12, 2016
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising The Nature Of Primary Care Patient Sa…
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psnet.ahrq.gov/node/46361/psn-pdf
May 23, 2018 - Inadequate hand-off communication.
May 23, 2018
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
https://psnet.ahrq.gov/issue/inadequate-hand-communication
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety
issues and provide guidelines fo…
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psnet.ahrq.gov/node/39336/psn-pdf
March 21, 2017 - Does teamwork improve performance in the operating
room? A multilevel evaluation.
March 21, 2017
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating
room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
https://psnet.ahrq.gov/issue/does-teamwork-im…
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psnet.ahrq.gov/node/40673/psn-pdf
September 03, 2011 - Evaluating efforts to optimize TeamSTEPPS
implementation in surgical and pediatric intensive care
units.
September 3, 2011
Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical
and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365-374.
htt…
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psnet.ahrq.gov/node/43514/psn-pdf
April 25, 2016 - A qualitative analysis of physician perspectives on
missed and delayed outpatient diagnosis: the focus on
system-related factors.
April 25, 2016
Sarkar U, Simchowitz B, Bonacum D, et al. A Qualitative Analysis of Physician Perspectives on Missed and
Delayed Outpatient Diagnosis: The Focus on System-Related Factors…
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psnet.ahrq.gov/node/46236/psn-pdf
April 03, 2018 - The impact of a diagnostic decision support system on
the consultation: perceptions of GPs and patients.
April 3, 2018
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the
consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
doi:10.1186/s12…
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psnet.ahrq.gov/node/42502/psn-pdf
October 07, 2013 - Patient safety in the cardiac operating room: human
factors and teamwork: a scientific statement from the
American Heart Association.
October 7, 2013
Wahr JA, Prager RL, Abernathy JH, et al. Patient Safety in the Cardiac Operating Room: Human Factors
and Teamwork. Circulation. 2013;128(10):1139-1169. doi:10.1161/c…
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psnet.ahrq.gov/node/60887/psn-pdf
September 09, 2020 - Human-based errors involving smart infusion pumps: a
catalog of error types and prevention strategies.
September 9, 2020
Kirkendall ES, Timmons K, Huth H, et al. Human-based errors involving smart infusion pumps: a catalog of
error types and prevention strategies. Drug Saf. 2020;43(11):1073-1087. doi:10.1007/s40264…
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psnet.ahrq.gov/node/45780/psn-pdf
March 15, 2017 - Overdose risk in young children of women prescribed
opioids.
March 15, 2017
Finkelstein Y, Macdonald EM, Gonzalez A, et al. Overdose Risk in Young Children of Women Prescribed
Opioids. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-2887.
https://psnet.ahrq.gov/issue/overdose-risk-young-children-women-prescribed-op…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - And then, of
course, there are tools that community pharmacies use to continue enhancing that safety
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Additionally, patients who feel heard and valued are more inclined to participate in their care, thereby enhancing
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - chest CT.( 15 ) Take-Home Points This patient’s experience illustrates several key points about enhancing
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psnet.ahrq.gov/node/40167/psn-pdf
January 22, 2017 - Trainees' perceptions of patient safety practices:
recounting failures of supervision.
January 22, 2017
Ross PT, McMyler ET, Anderson SG, et al. Trainees' perceptions of patient safety practices: recounting
failures of supervision. Jt Comm J Qual Patient Saf. 2011;37(2):88-95.
https://psnet.ahrq.gov/issue/trainees…
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psnet.ahrq.gov/node/46110/psn-pdf
January 01, 2019 - Examination of the relationship between management and
clinician perception of patient safety climate and patient
satisfaction.
December 21, 2018
Mazurenko O, Richter J, Kazley AS, et al. Examination of the relationship between management and
clinician perception of patient safety climate and patient satisfaction.…
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psnet.ahrq.gov/node/36168/psn-pdf
August 31, 2011 - Computerized prescribing alerts and group academic
detailing to reduce the use of potentially inappropriate
medications in older people.
August 31, 2011
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to
reduce the use of potentially inappropriate medications i…
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psnet.ahrq.gov/node/47088/psn-pdf
May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018
User Database Report.
May 2, 2018
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2018. AHRQ Publication No. 18-0030-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…