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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/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/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/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/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/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/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…
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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/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/46895/psn-pdf
March 14, 2018 - Rapid response teams: what's the latest?
March 14, 2018
Jackson SA. Rapid response teams: What's the latest? Nursing (Brux). 2017;47(12):34-41.
doi:10.1097/01.NURSE.0000526885.10306.21.
https://psnet.ahrq.gov/issue/rapid-response-teams-whats-latest
Rapid response systems are an established strategy to prevent in-h…
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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/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/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
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psnet.ahrq.gov/node/43625/psn-pdf
October 29, 2014 - Assessing distractors and teamwork during surgery:
developing an event-based method for direct observation.
October 29, 2014
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an
event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
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psnet.ahrq.gov/node/44118/psn-pdf
May 19, 2018 - Inadequate preoperative team briefings lead to more
intraoperative adverse events.
May 19, 2018
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative
Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
https://psnet.ahrq.gov/issue/inadequate-…
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psnet.ahrq.gov/node/45975/psn-pdf
May 07, 2018 - Two effective initiatives for C-suite leaders to improve
medication safety and the reliability of outcomes.
May 7, 2018
ISMP Medication Safety Alert! Acute care edition. March 23, 2017;22:1-5.
https://psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-
reliability-outcomes…
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psnet.ahrq.gov/node/47419/psn-pdf
January 22, 2019 - Implementing safety hotlines: Stamford Health's
experience and future opportunities.
January 22, 2019
Cardiello R, Johnston S, Kiely S. Implementing safety hotlines: Stamford Health's experience and future
opportunities. J Healthc Risk Manag. 2019;38(3):24-31. doi:10.1002/jhrm.21347.
https://psnet.ahrq.gov/issue/i…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46348/psn-pdf
June 13, 2018 - The nexus of nursing leadership and a culture of safer
patient care.
June 13, 2018
Murray M, Sundin D, Cope V. The nexus of nursing leadership and a culture of safer patient care. J Clin
Nurs. 2018;27(5-6):1287-1293. doi:10.1111/jocn.13980.
https://psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-pa…
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psnet.ahrq.gov/node/44691/psn-pdf
December 02, 2015 - Quality and safety in orthopaedics: learning and teaching
at the same time: AOA critical issues.
December 2, 2015
Black KP, Armstrong AD, Hutzler L, et al. Quality and Safety in Orthopaedics: Learning and Teaching at the
Same Time: AOA Critical Issues. J Bone Joint Surg Am. 2015;97(21):1809-15. doi:10.2106/JBJS.O.0…