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psnet.ahrq.gov/node/42415/psn-pdf
July 24, 2013 - Strategies for improving communication in the
emergency department: mediums and messages in a
noisy environment.
July 24, 2013
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency
department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…
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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/45526/psn-pdf
January 01, 2019 - Improving incident reporting among physician trainees.
September 28, 2016
Krouss M, Alshaikh J, Croft LD, et al. Improving Incident Reporting Among Physician Trainees. J Patient
Saf. 2019;15(4):308-310. doi:10.1097/PTS.0000000000000325.
https://psnet.ahrq.gov/issue/improving-incident-reporting-among-physician-train…
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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/41438/psn-pdf
January 03, 2017 - Implementing SBAR across a large multihospital health
system.
January 3, 2017
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system.
Jt Comm J Qual Patient Saf. 2012;38(6):261-8.
https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…
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psnet.ahrq.gov/node/43123/psn-pdf
August 04, 2015 - Redesigning surgical decision making for high-risk
patients.
August 4, 2015
Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J
Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538.
https://psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patient…
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psnet.ahrq.gov/node/44495/psn-pdf
September 30, 2015 - Impact of laws aimed at healthcare-associated infection
reduction: a qualitative study.
September 30, 2015
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated
infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.1136/bmjqs-2014-
003921.
htt…
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psnet.ahrq.gov/node/43252/psn-pdf
August 24, 2016 - Patient Safety: Perspectives on Evidence, Information and
Knowledge Transfer.
August 24, 2016
Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.
https://psnet.ahrq.gov/issue/patient-safety-perspectives-evidence-information-and-knowledge-transfer
This book provides information about utilizing …
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psnet.ahrq.gov/node/854639/psn-pdf
October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us
to Thrive.
October 18, 2023
Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.
https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
Despite the harm that failure can cause, its value as a learning opportunity, if exam…
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psnet.ahrq.gov/node/47485/psn-pdf
January 09, 2019 - System-related and cognitive errors in laboratory
medicine.
January 9, 2019
Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191-
196. doi:10.1515/dx-2018-0085.
https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine
Problems managing …
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psnet.ahrq.gov/node/72583/psn-pdf
December 16, 2020 - Wear face masks with no metal during MRI exams.
December 16, 2020
FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug
Administration; December 7, 2020.
https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
Magnetic resonance imaging (MRI) requires patient prep…
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psnet.ahrq.gov/node/43335/psn-pdf
July 09, 2014 - Wake Up Safe and root cause analysis: quality
improvement in pediatric anesthesia.
July 9, 2014
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in
pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47734/psn-pdf
March 13, 2019 - Medicare trims payments to 800 hospitals, citing patient
safety incidents.
March 13, 2019
Rau J. Kaiser Health News. March 1, 2019.
https://psnet.ahrq.gov/issue/medicare-trims-payments-800-hospitals-citing-patient-safety-incidents
Financial incentives may encourage adoption of practice improvements that enhance sa…
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/45551/psn-pdf
November 30, 2016 - Parents' perspectives on "keeping their children safe" in
the hospital.
November 30, 2016
Rosenberg RE, Rosenfeld P, Williams E, et al. Parents' Perspectives on "Keeping Their Children Safe" in
the Hospital. J Nurs Care Qual. 2016;31(4):318-326. doi:10.1097/NCQ.0000000000000193.
https://psnet.ahrq.gov/issue/parent…
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psnet.ahrq.gov/node/46174/psn-pdf
August 30, 2017 - Inpatients notes: sensemaking—fostering a shared
understanding in clinical teams.
August 30, 2017
Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering
a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17-
1829.
https://psn…
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psnet.ahrq.gov/node/73354/psn-pdf
June 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal
Mortality Workshop.
June 2, 2021
National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.
https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop
Maternal safety is challenged by clinical, equity…
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psnet.ahrq.gov/node/43458/psn-pdf
August 27, 2014 - Validation of a teamwork perceptions measure to increase
patient safety.
August 27, 2014
Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient
safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942.
https://psnet.ahrq.gov/issue/validation-teamwork…
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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/47749/psn-pdf
June 19, 2019 - A simulation-based approach to training in heuristic
clinical decision-making.
June 19, 2019
Altabbaa G, Raven AD, Laberge J. A simulation-based approach to training in heuristic clinical decision-
making. Diagnosis (Berl). 2019;6(2):91-99. doi:10.1515/dx-2018-0084.
https://psnet.ahrq.gov/issue/simulation-based-ap…