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psnet.ahrq.gov/node/34771/psn-pdf
May 06, 2016 - Managing the Unexpected: Sustained Performance in a
Complex World, Third Edition.
May 6, 2016
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
https://psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
According to Weick and Sutcliffe, high…
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psnet.ahrq.gov/node/866083/psn-pdf
June 05, 2024 - An invisible disability: communication, patient safety and
dual sensory impairment in older persons.
June 5, 2024
Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual
sensory impairment in older persons. J Adv Nurs. 2024;Epub Mar 22. doi:10.1111/jan.16159.
https://p…
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psnet.ahrq.gov/node/865926/psn-pdf
May 22, 2024 - Critical care nurses' role in rapid response teams: a
qualitative systematic review.
May 22, 2024
Holtsmark C, Larsen MH, Steindal SA, et al. Critical care nurses' role in rapid response teams: a qualitative
systematic review. J Clin Nurs. 2024;33(10):3831-3843. doi:10.1111/jocn.17196.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60959/psn-pdf
September 30, 2020 - Institutional COVID-19 protocols: focused on preparation,
safety, and care consolidation.
September 30, 2020
DiSilvio B, Virani A, Patel S, et al. Institutional COVID-19 protocols: focused on preparation, safety, and
care consolidation. Crit Care Nurs Q. 2020;43(4):413-427. doi:10.1097/cnq.0000000000000327.
https:…
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psnet.ahrq.gov/node/43187/psn-pdf
May 28, 2014 - Governance of quality of care: a qualitative study of
health service boards in Victoria, Australia.
May 28, 2014
Bismark M, Studdert DM. Governance of quality of care: a qualitative study of health service boards in
Victoria, Australia. BMJ Qual Saf. 2014;23(6):474-82. doi:10.1136/bmjqs-2013-002193.
https://psnet.…
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psnet.ahrq.gov/node/35265/psn-pdf
February 03, 2011 - A 38-year-old woman with fetal loss and hysterectomy.
February 3, 2011
Sachs BP. A 38-Year-Old Woman With Fetal Loss and Hysterectomy. JAMA. 2005;294(7):833-840.
doi:10.1001/jama.294.7.833.
https://psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy
Part of a series in JAMA entitled Clinical Crossro…
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psnet.ahrq.gov/node/44772/psn-pdf
January 13, 2016 - Post event debriefs: a commitment to learning how to
better care for patients and staff.
January 13, 2016
Campbell M, Miller K, McNicholas KW. Post Event Debriefs: A Commitment to Learning How to Better Care
for Patients and Staff. Jt Comm J Qual Patient Saf. 2016;42(1):41-47.
https://psnet.ahrq.gov/issue/post-eve…
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psnet.ahrq.gov/node/41020/psn-pdf
January 04, 2012 - A 'Communication and Patient Safety' training programme
for all healthcare staff: can it make a difference?
January 4, 2012
Lee P, Allen K, Daly M. A ‘Communication and Patient Safety’ training programme for all healthcare staff:
can it make a difference? BMJ Qual Saf. 2011;21(1). doi:10.1136/bmjqs-2011-000297.
ht…
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psnet.ahrq.gov/node/43261/psn-pdf
June 18, 2014 - Activation of a medical emergency team using an
electronic medical recording–based screening system.
June 18, 2014
Huh JW, Lim C-M, Koh Y, et al. Activation of a medical emergency team using an electronic medical
recording-based screening system*. Crit Care Med. 2014;42(4):801-8.
doi:10.1097/CCM.0000000000000031.
…
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psnet.ahrq.gov/node/837041/psn-pdf
May 04, 2022 - APSF endorsed statement on revising recommendations
for patient monitoring during anesthesia.
May 4, 2022
The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.
https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-
anesthesia
Variation across sta…
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psnet.ahrq.gov/node/45009/psn-pdf
March 30, 2016 - Fatal mistakes.
March 30, 2016
Kliff S. Vox Media. March 15, 2016.
https://psnet.ahrq.gov/issue/fatal-mistakes
Health professionals involved in medical errors experience psychological stress, which can have serious
consequences if they are unable to cope with their mistake. Reporting on the second victim phenomeno…
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psnet.ahrq.gov/node/44662/psn-pdf
January 25, 2016 - The stories clinicians tell: achieving high reliability and
improving patient safety.
January 25, 2016
Cohen DL, Stewart KO. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety.
Perm J. 2016;20(1):85-90. doi:10.7812/TPP/15-039.
https://psnet.ahrq.gov/issue/stories-clinicians-tell-a…
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psnet.ahrq.gov/node/43109/psn-pdf
December 10, 2014 - Creating a physician-led quality imperative.
December 10, 2014
Nelson MF, Merriman CS, Magnusson PT, et al. Creating a physician-led quality imperative. Am J Med
Qual. 2014;29(6):508-16. doi:10.1177/1062860613509683.
https://psnet.ahrq.gov/issue/creating-physician-led-quality-imperative
This commentary relates one…
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psnet.ahrq.gov/node/45736/psn-pdf
February 01, 2017 - Disruptive behaviour in the perioperative setting: a
contemporary review.
February 1, 2017
Villafranca A, Hamlin C, Enns S, et al. Disruptive behaviour in the perioperative setting: a contemporary
review. Canadian J Anaesth. 2017;64(2):128-140. doi:10.1007/s12630-016-0784-x.
https://psnet.ahrq.gov/issue/disruptive…
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psnet.ahrq.gov/node/44548/psn-pdf
November 20, 2015 - Safety-II and resilience: the way ahead in patient safety in
anaesthesiology.
November 20, 2015
Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin
Anaesthesiol. 2015;28(6):735-9. doi:10.1097/ACO.0000000000000252.
https://psnet.ahrq.gov/issue/safety-ii-and-resilience…
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psnet.ahrq.gov/node/44231/psn-pdf
January 22, 2016 - Just-in-time training for high-risk low-volume therapies:
an approach to ensure patient safety.
January 22, 2016
Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An
Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-9.
doi:10.1097/NCQ.0000000000000131.…
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psnet.ahrq.gov/node/46741/psn-pdf
June 07, 2018 - Suffering in silence: medical error and its impact on
health care providers.
June 7, 2018
Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J
Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001.
https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…
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psnet.ahrq.gov/node/46328/psn-pdf
August 09, 2017 - Critical incident stress debriefing after adverse patient
safety events.
August 9, 2017
Harrison R, Wu AW. Critical incident stress debriefing after adverse patient safety events. Am J Med Qual.
2017;23(5):310-312.
https://psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events…
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psnet.ahrq.gov/node/850912/psn-pdf
June 21, 2023 - Racial, Ethnic, and Payer Disparities in Adverse Safety
Events: Are there Differences across Leapfrog Hospital
Safety Grades?
June 21, 2023
Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.
https://psnet.ahrq.gov/issue/racial-ethnic-and-payer-disparities-adverse-safety-events-are…
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psnet.ahrq.gov/node/863227/psn-pdf
February 28, 2024 - What Do You Do If You Think You Have Been Harmed By
Your Healthcare.
February 28, 2024
Seattle, WA: Collaborative for Accountability and Improvement; 2023.
https://psnet.ahrq.gov/issue/what-do-you-do-if-you-think-you-have-been-harmed-your-healthcare
There is a need for patients and families to understand effective…