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psnet.ahrq.gov/node/47387/psn-pdf
September 12, 2018 - Guideline implementation: team communication.
September 12, 2018
Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J.
2018;108(2):165-177. doi:10.1002/aorn.12300.
https://psnet.ahrq.gov/issue/guideline-implementation-team-communication
Although team development has rec…
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psnet.ahrq.gov/node/44475/psn-pdf
October 03, 2017 - Scoring no goal—further adventures in transparency.
October 3, 2017
Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385-
8. doi:10.1056/NEJMp1510094.
https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency
This commentary explores challenges to mon…
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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/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/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/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/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/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/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/73255/psn-pdf
May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care.
May 12, 2021
National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National
Academies Press.
https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care
Primary…
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psnet.ahrq.gov/node/44281/psn-pdf
July 22, 2015 - Surgeon Scorecard.
July 22, 2015
Wei S; Allen M; Pierce O.
https://psnet.ahrq.gov/issue/surgeon-scorecard
Transparency has been advocated as a key element of safe, patient-centered care, but data on individual
performance has not been made widely available. This database compiles the death and complication
rates …
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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/42856/psn-pdf
January 07, 2015 - Clinical benefits of electronic health record use: national
findings.
January 7, 2015
King J, Patel V, Jamoom EW, et al. Clinical benefits of electronic health record use: national findings.
Health Serv Res. 2014;49(1 Pt 2):392-404. doi:10.1111/1475-6773.12135.
https://psnet.ahrq.gov/issue/clinical-benefits-electr…
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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/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/45569/psn-pdf
January 23, 2017 - Patient experience must move beyond bad apples.
January 23, 2017
Hamedani A, Safdar B, Aaronson E, et al. Patient Experience Must Move Beyond Bad Apples. Ann Intern
Med. 2016;165(12):869-870. doi:10.7326/M16-1725.
https://psnet.ahrq.gov/issue/patient-experience-must-move-beyond-bad-apples
Patient safety leaders ha…
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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/42984/psn-pdf
February 26, 2014 - Delivering the truth: challenges and opportunities for
error disclosure in obstetrics.
February 26, 2014
Carranza L, Lyerly AD, Lipira L, et al. Delivering the Truth. Obstetrics & Gynecology. 2014;123(3).
doi:10.1097/aog.0000000000000130.
https://psnet.ahrq.gov/issue/delivering-truth-challenges-and-opportunities-e…
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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/72734/psn-pdf
February 10, 2021 - Meitheal Pharmaceuticals, Inc. issues voluntary
nationwide recall of Cisatracurium Besylate Injection,
USP 10mg per 5mL due to mislabeling.
February 10, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.
https://psnet.ahrq.gov/issue/meitheal-pharmaceuticals-inc…