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psnet.ahrq.gov/node/45150/psn-pdf
October 13, 2018 - Pain as the neglected patient safety concern: five years
on.
October 13, 2018
Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J
Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422.
https://psnet.ahrq.gov/issue/pain-neglected-patient-safety-conce…
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psnet.ahrq.gov/node/41971/psn-pdf
January 23, 2013 - Behavioral integrity for safety, priority of safety,
psychological safety, and patient safety: a team-level
study.
January 23, 2013
Leroy H, Dierynck B, Anseel F, et al. Behavioral integrity for safety, priority of safety, psychological safety,
and patient safety: A team-level study. Journal of Applied Psychology.…
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psnet.ahrq.gov/node/46080/psn-pdf
August 28, 2017 - A growth mindset approach to preparing trainees for
medical error.
August 28, 2017
Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error.
BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416.
https://psnet.ahrq.gov/issue/growth-mindset-approach-preparing…
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psnet.ahrq.gov/node/46244/psn-pdf
June 28, 2017 - Changing the narratives for patient safety.
June 28, 2017
Pronovost P, Sutcliffe K, Basu L, et al. Changing the narratives for patient safety. Bull World Health Organ.
2017;95(6):478-480. doi:10.2471/BLT.16.178392.
https://psnet.ahrq.gov/issue/changing-narratives-patient-safety
Mental models represent established …
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psnet.ahrq.gov/node/41388/psn-pdf
May 30, 2012 - Observational teamwork assessment for surgery:
feasibility of clinical and nonclinical assessor calibration
with short-term training.
May 30, 2012
Russ S, Hull L, Rout S, et al. Observational teamwork assessment for surgery: feasibility of clinical and
nonclinical assessor calibration with short-term training. Ann…
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psnet.ahrq.gov/node/46076/psn-pdf
September 24, 2017 - The evolving story of overlapping surgery.
September 24, 2017
Mello MM, Livingston EH. The Evolving Story of Overlapping Surgery. JAMA. 2017;318(3):233-234.
doi:10.1001/jama.2017.8061.
https://psnet.ahrq.gov/issue/evolving-story-overlapping-surgery
Scheduling overlapping procedures is perceived as risky, despite l…
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psnet.ahrq.gov/node/39072/psn-pdf
November 04, 2009 - Variations in nursing care quality across hospitals.
November 4, 2009
Lucero RJ, Lake ET, Aiken LH. Variations in nursing care quality across hospitals. J Adv Nurs.
2009;65(11):2299-310. doi:10.1111/j.1365-2648.2009.05090.x.
https://psnet.ahrq.gov/issue/variations-nursing-care-quality-across-hospitals
This seconda…
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psnet.ahrq.gov/node/45689/psn-pdf
January 25, 2018 - How to prevent burnout (maybe).
January 25, 2018
Dissanaike S. How to prevent burnout (maybe). Am J Surg. 2016;212(6):1251-1255.
doi:10.1016/j.amjsurg.2016.08.022.
https://psnet.ahrq.gov/issue/how-prevent-burnout-maybe
Burnout can affect the ability of individuals and teams to act safely. Originally delivered as a…
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psnet.ahrq.gov/node/44729/psn-pdf
January 07, 2016 - The morbidity and mortality meeting: time for a different
approach?
January 7, 2016
Fraser J. The morbidity and mortality meeting: time for a different approach? Arch Dis Child. 2016;101(1):4-
8. doi:10.1136/archdischild-2015-309536.
https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-appro…
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psnet.ahrq.gov/node/45564/psn-pdf
October 03, 2017 - Fostering transparency in outcomes, quality, safety, and
costs.
October 3, 2017
Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs.
JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039.
https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-a…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - Hospital and procedure incidence of pediatric retained
surgical items.
September 9, 2015
Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J
Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054.
https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
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psnet.ahrq.gov/node/44682/psn-pdf
March 15, 2016 - On resident duty hour restrictions and neurosurgical
training: review of the literature.
March 15, 2016
Bina RW, Lemole M, Dumont TM. On resident duty hour restrictions and neurosurgical training: review of
the literature. J Neurosurg. 2016;124(3):842-8. doi:10.3171/2015.3.JNS142796.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/45232/psn-pdf
August 10, 2016 - Promoting patient safety with perioperative hand-off
communication.
August 10, 2016
Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs.
2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144.
https://psnet.ahrq.gov/issue/promoting-patient-safety-perioperative-hand-commun…
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psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - Are second victims getting the help they need?
June 20, 2018
Headley M. Patient Saf Qual Healthc. May/June 2018.
https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are
increasingly building p…
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psnet.ahrq.gov/node/46360/psn-pdf
October 25, 2017 - Creating a culture of caregiver support.
October 25, 2017
Gold KJ, Andrew LB, Goldman EB, et al. “I would never want to have a mental health diagnosis on my
record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. General
Hospital Psychiatry. 2016;43. doi:10.1016/j.genhosppsych.2…
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psnet.ahrq.gov/node/40643/psn-pdf
July 27, 2011 - Does the implementation of an electronic prescribing
system create unintended medication errors? A study of
the sociotechnical context through the analysis of
reported medication incidents.
July 27, 2011
Redwood S, Rajakumar A, Hodson J, et al. Does the implementation of an electronic prescribing system
create un…
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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/46457/psn-pdf
December 20, 2017 - Simulation and the diagnostic process: a pilot study of
trauma and rapid response teams.
December 20, 2017
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and
rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/dx-2017-0010.
https://psnet.ah…
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psnet.ahrq.gov/node/39972/psn-pdf
January 22, 2017 - Executive/senior leader checklist to improve culture and
reduce central line–associated bloodstream infections.
January 22, 2017
Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Executive/Senior Leader Checklist to improve culture
and reduce central line-associated bloodstream infections. Jt Comm J Qual Patient S…