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psnet.ahrq.gov/node/45083/psn-pdf
July 18, 2016 - Toward a safer health care system: the critical need to
improve measurement.
July 18, 2016
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement.
JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448.
https://psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-n…
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psnet.ahrq.gov/node/47760/psn-pdf
February 06, 2019 - AHRQ National Scorecard on Hospital-Acquired
Conditions Updated Baseline Rates and Preliminary
Results 2014–2017.
February 6, 2019
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
https://psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-
and-…
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psnet.ahrq.gov/node/867350/psn-pdf
December 11, 2024 - Surveys on Patient Safety Culture (SOPS) Hospital Survey
2.0: User Database Report.
December 11, 2024
Tyler ER, Yalden O, Fan L, et al. Surveys On Patient Safety Culture (Sops) Hospital Survey 2.0: User
Database Report. Rockville, MD: Agency for Healthcare Research and Quality; November 2024. AHRQ
Publication No. …
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psnet.ahrq.gov/node/37757/psn-pdf
March 10, 2011 - Workarounds to barcode medication administration
systems: their occurrences, causes, and threats to patient
safety.
March 10, 2011
Koppel R, Wetterneck TB, Telles JL, et al. Workarounds to barcode medication administration systems:
their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/39338/psn-pdf
April 30, 2014 - The effect of multidisciplinary care teams on intensive
care unit mortality.
April 30, 2014
Kim MM, Barnato AE, Angus DC, et al. The effect of multidisciplinary care teams on intensive care unit
mortality. Arch Intern Med. 2010;170(4):369-76. doi:10.1001/archinternmed.2009.521.
https://psnet.ahrq.gov/issue/effect-…
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumkutn.html
October 01, 2014 - Kutney Lee, Ann
Summaries of Independent Scientist (K) Awards
Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards.
Institution: University of Pennsylvania
Grant Title: Changes in Hospital Care Organization and Outcomes
Grant Number: K08…
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psnet.ahrq.gov/node/42917/psn-pdf
February 05, 2014 - The PROMISES Project.
February 5, 2014
Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the
Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School;
Health Care for All; Massachusetts Medical Society; Massachusetts Departme…
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumcoch.html
October 01, 2014 - Cochran, Gary
Summaries of Independent Scientist (K) Awards
Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards.
Institution: University of Nebraska Medical Center
Grant Title: Comparing the Effectiveness of Medication Use Systems in Small…
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumlafl.html
October 01, 2014 - Lafleur, Joanne
Summaries of Independent Scientist (K) Awards
Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards.
Institution: University of Utah
Grant Title: Knowledge Engineering for Decision Support in Osteoporosis
Grant Number: K08…
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psnet.ahrq.gov/node/50458/psn-pdf
October 09, 2019 - Success of a resident-led safety council: a model for
satisfying CLER Pathways to Excellence patient safety
goals.
October 9, 2019
Cohen SP, Pelletier JH, Ladd JM, et al. Success of a resident-led safety council: a model for satisfying
CLER Pathways to Excellence patient safety goals. J Gen Intern Med. 2019;11(2):…
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psnet.ahrq.gov/node/41983/psn-pdf
January 16, 2013 - A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness.
January 16, 2013
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and
clinical safety and effectiveness. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-0015…
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psnet.ahrq.gov/node/45461/psn-pdf
January 03, 2017 - Operating room–to-ICU patient handovers: a
multidisciplinary human-centered design approach.
January 3, 2017
Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary
Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9):400-14.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43041/psn-pdf
January 06, 2015 - Through the Eyes of the Workforce: Creating Joy,
Meaning, and Safer Health Care.
January 6, 2015
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA:
National Patient Safety Foundation; 2013.
https://psnet.ahrq.gov/issue/through-eyes-workforce-creating-joy-meaning-and…
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psnet.ahrq.gov/node/46531/psn-pdf
January 24, 2019 - Tracking progress in improving diagnosis: a framework
for defining undesirable diagnostic events.
January 24, 2019
Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining
Undesirable Diagnostic Events. J Gen Intern Med. 2018;33(7):1187-1191. doi:10.1007/s11606-018-4304-2.
ht…
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psnet.ahrq.gov/node/39396/psn-pdf
November 02, 2014 - Unmet Needs: Teaching Physicians to Provide Safe
Patient Care.
November 2, 2014
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
Medical schools face an urgent need to transform their cur…
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psnet.ahrq.gov/node/46339/psn-pdf
August 20, 2018 - Association of the Hospital Readmissions Reduction
Program implementation with readmission and mortality
outcomes in heart failure.
August 20, 2018
Gupta A, Allen LA, Bhatt DL, et al. Association of the Hospital Readmissions Reduction Program
Implementation With Readmission and Mortality Outcomes in Heart Failure.…
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psnet.ahrq.gov/node/60315/psn-pdf
May 13, 2020 - Safety at the time of the COVID-19 pandemic: how to keep
our oncology patients and healthcare workers safe.
May 13, 2020
Cinar P, Kubal T, Freifeld A, et al. Safety at the time of the COVID-19 pandemic: how to keep our oncology
patients and healthcare workers safe. J Natl Compr Canc Netw. 2020;18(5):504-509.
doi:1…
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psnet.ahrq.gov/node/46236/psn-pdf
April 03, 2018 - The impact of a diagnostic decision support system on
the consultation: perceptions of GPs and patients.
April 3, 2018
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the
consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
doi:10.1186/s12…
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psnet.ahrq.gov/node/43401/psn-pdf
August 02, 2015 - Morning handover of on-call issues: opportunities for
improvement.
August 2, 2015
Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement.
JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033.
https://psnet.ahrq.gov/issue/morning-handover-call-issu…
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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
htt…