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psnet.ahrq.gov/node/47539/psn-pdf
November 28, 2018 - The star of the diagnostic journey: assessing patient
perspectives.
November 28, 2018
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
https://psnet.ahrq.gov/issue/star-diagnostic-journey-assessing-patient-perspectives
Patients are increasingly seen as partners in efforts to improve health ca…
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psnet.ahrq.gov/node/43185/psn-pdf
May 14, 2014 - Preventing health care–associated harm in children.
May 14, 2014
Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA.
2014;311(17):1731-2. doi:10.1001/jama.2014.2038.
https://psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children
This commentary describes why de…
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psnet.ahrq.gov/node/44550/psn-pdf
September 30, 2015 - Infections associated with reprocessed flexible
bronchoscopes.
September 30, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
https://psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes
Use of incompletely cleaned medical devices has b…
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psnet.ahrq.gov/node/50805/psn-pdf
January 15, 2020 - Advancing safety with closed-loop communication of test
results.
January 15, 2020
Quick Safety. December 17, 2019;(52):1-3.
https://psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares…
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psnet.ahrq.gov/node/42370/psn-pdf
June 19, 2013 - Resident Projects for Improvement.
June 19, 2013
Heilman J, ed. UNM CIR Journal of Quality Improvement in Healthcare. Albuquerque, NM: University of
New Mexico; May 2013.
https://psnet.ahrq.gov/issue/journal-quality-improvement-healthcare-second-edition
This publication outlines quality and safety improvement proj…
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psnet.ahrq.gov/node/43591/psn-pdf
August 02, 2015 - The automated operating room: a team approach to
patient safety and communication.
August 2, 2015
Nissan J, Campos V, Delgado H, et al. The automated operating room: a team approach to patient safety
and communication. JAMA Surg. 2014;149(11):1209-10. doi:10.1001/jamasurg.2014.1825.
https://psnet.ahrq.gov/issue/au…
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psnet.ahrq.gov/node/44912/psn-pdf
November 18, 2016 - Patient safety in genomic medicine: an exploratory study.
November 18, 2016
Korngiebel DM, Fullerton SM, Burke W. Patient safety in genomic medicine: an exploratory study. Genet
Med. 2016;18(11):1136-1142. doi:10.1038/gim.2016.16.
https://psnet.ahrq.gov/issue/patient-safety-genomic-medicine-exploratory-study
This …
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psnet.ahrq.gov/node/41360/psn-pdf
September 30, 2012 - The simulated ward: ideal for training clinical clerks in an
era of patient safety.
September 30, 2012
Mollo EA, Reinke CE, Nelson C, et al. The simulated ward: ideal for training clinical clerks in an era of
patient safety. J Surg Res. 2012;177(1):e1-6. doi:10.1016/j.jss.2012.03.050.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43152/psn-pdf
May 07, 2014 - The trainee's voice: recognising the importance of
preoperative briefings for surgical trainees.
May 7, 2014
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for
surgical trainees. J Perioper Pract. 2014;24(3):56-58.
https://psnet.ahrq.gov/issue/trainees-voice-recog…
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psnet.ahrq.gov/node/34782/psn-pdf
November 01, 2016 - When systems fail.
November 1, 2016
Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090-
2616(01)00025-0.
https://psnet.ahrq.gov/issue/when-systems-fail
This review provides a detailed account of managerial causes of failure and managerial failure prevention
strategies. The aut…
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psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
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psnet.ahrq.gov/node/44503/psn-pdf
November 18, 2024 - Certified Professional in Patient Safety Review Course.
November 18, 2024
Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern).
https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course
This online class prepares individuals to apply for the Institute for Healthca…
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psnet.ahrq.gov/node/44703/psn-pdf
December 16, 2015 - Defining the Role of Social Sciences in Patient Safety.
December 16, 2015
Su L, Fernandez R, Grand J, et al, eds. Curr Probl Pediatr Adolesc Health Care. 2015;45:365-394.
https://psnet.ahrq.gov/issue/defining-role-social-sciences-patient-safety
Applying principles from other fields, such as aviation and nuclear pow…
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psnet.ahrq.gov/node/43322/psn-pdf
January 28, 2015 - Patient Safety Initiative: Hospital Executive and Physician
Leadership Strategies.
January 28, 2015
Oakbrook, IL: Joint Commission Resources; January 2014.
https://psnet.ahrq.gov/issue/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies
This toolkit draws from experiences of the Joint …
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psnet.ahrq.gov/node/860400/psn-pdf
January 10, 2024 - AHA Patient Safety Initiative.
January 10, 2024
American Hospital Association.
https://psnet.ahrq.gov/issue/aha-patient-safety-initiative
Leadership at the organization and system level is crucial to gaining improvement traction and
sustainability. This initiative centers on safety culture, care inequities, and wo…
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psnet.ahrq.gov/node/37216/psn-pdf
July 28, 2010 - Discharge rounds in the 80-hour workweek: importance of
the trauma nurse practitioner.
July 28, 2010
Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma
nurse practitioner. J Trauma. 2007;63(2):339-43.
https://psnet.ahrq.gov/issue/discharge-rounds-80-hour-workwee…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/845658/psn-pdf
June 08, 2023 - Simulation Articles of Influence.
June 8, 2023
Society for Simulation in Healthcare. 2017-2023.
https://psnet.ahrq.gov/issue/simulation-articles-influence
Simulation can be used to reveal teamwork coordination gaps and latent factors that contribute to failure.
This article collection has been curated by experts i…
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psnet.ahrq.gov/node/40658/psn-pdf
August 03, 2011 - Development and validation of a tool to improve
paediatric referral/consultation communication.
August 3, 2011
Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric
referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. doi:10.1136/bmjqs.2010.045781.
https:…
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psnet.ahrq.gov/node/43356/psn-pdf
July 16, 2014 - Introducing the safety score audit for staff member and
patient safety.
July 16, 2014
Sinnott M, Eley R, Winch S. Introducing the safety score audit for staff member and patient safety. AORN
J. 2014;100(1):91-5. doi:10.1016/j.aorn.2014.05.006.
https://psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-membe…