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psnet.ahrq.gov/node/38143/psn-pdf
February 18, 2011 - A multidisciplinary teamwork training program: The Triad
for Optimal Patient Safety (TOPS) experience.
February 18, 2011
Sehgal NL, Fox M, Vidyarthi A, et al. A multidisciplinary teamwork training program: the Triad for Optimal
Patient Safety (TOPS) experience. J Gen Intern Med. 2008;23(12):2053-7. doi:10.1007/s116…
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psnet.ahrq.gov/node/42363/psn-pdf
September 19, 2013 - e-Prescribing: characterisation of patient safety hazards
in community pharmacies using a sociotechnical systems
approach.
September 19, 2013
Odukoya OK, Chui MA. e-Prescribing: characterisation of patient safety hazards in community pharmacies
using a sociotechnical systems approach. BMJ Qual Saf. 2013;22(10):816…
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psnet.ahrq.gov/node/866411/psn-pdf
July 31, 2024 - Simulation to Improve Patient Safety: Getting Started.
July 31, 2024
Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for
Healthcare Research and Quality; July 2024. Publication No. 24-0055.
https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…
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psnet.ahrq.gov/node/60034/psn-pdf
March 11, 2020 - Responding to unprofessional behavior by trainees - a
"just culture" framework.
March 11, 2020
Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just
Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591.
https://psnet.ahrq.gov/issue/resp…
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psnet.ahrq.gov/node/838623/psn-pdf
October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/44888/psn-pdf
April 06, 2016 - Transforming the morbidity and mortality conference to
promote safety and quality in a PICU.
April 6, 2016
Cifra CL, Bembea MM, Fackler JC, et al. Transforming the morbidity and mortality conference to promote
safety and quality in a PICU. Crit Care Med. 2016;17(1):58-66. doi:10.1097/PCC.0000000000000539.
https://…
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psnet.ahrq.gov/node/35253/psn-pdf
April 06, 2011 - Real time patient safety audits: improving safety every
day.
April 6, 2011
Ursprung R. Real time patient safety audits: improving safety every day. Qual Saf Health Care.
2005;14(4):284-289. doi:10.1136/qshc.2004.012542.
https://psnet.ahrq.gov/issue/real-time-patient-safety-audits-improving-safety-every-day
This p…
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psnet.ahrq.gov/node/851199/psn-pdf
July 05, 2023 - Understanding the root cause analysis process to
increase safety event reporting.
July 5, 2023
Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J.
2023;117(6):399-402. doi:10.1002/aorn.13935.
https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-inc…
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psnet.ahrq.gov/node/46909/psn-pdf
August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working
Party.
August 1, 2018
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party
Lack of appropriate staffing can diminish the safety and effectiveness of medical service…
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psnet.ahrq.gov/node/44807/psn-pdf
September 29, 2017 - Legal and policy interventions to improve patient safety.
September 29, 2017
Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety.
Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880.
https://psnet.ahrq.gov/issue/legal-and-policy-interventions-impro…
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psnet.ahrq.gov/node/61123/psn-pdf
November 11, 2020 - Organizational Evidence-Based and Promising Practices
for Improving Clinician Well-Being.
November 11, 2020
Sinsky CA, Biddison LD, Mallick A, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2020.
https://psnet.ahrq.gov/issue/organizational-evidence-based-and-promising-practices-improvin…
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psnet.ahrq.gov/node/44062/psn-pdf
September 09, 2015 - How to make medication error reporting systems
work—factors associated with their successful
development and implementation.
September 9, 2015
Holmström A-R, Laaksonen R, Airaksinen M. How to make medication error reporting systems work--
Factors associated with their successful development and implementation. Hea…
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psnet.ahrq.gov/node/43138/psn-pdf
April 23, 2014 - The quest for safe surgical care: are we missing the
obvious?
April 23, 2014
Shuhaiber J. The quest for safe surgical care: are we missing the obvious? Bull Am Coll Surg.
2014;99(2):42-5.
https://psnet.ahrq.gov/issue/quest-safe-surgical-care-are-we-missing-obvious
Many studies have examined how checklists impact …
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psnet.ahrq.gov/node/37120/psn-pdf
March 24, 2011 - Patient safety culture in primary care: developing a
theoretical framework for practical use.
March 24, 2011
Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical
framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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psnet.ahrq.gov/node/73365/psn-pdf
June 09, 2021 - Enhancing psychological safety in mental health services.
June 9, 2021
Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment
Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1.
https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…
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psnet.ahrq.gov/node/867754/psn-pdf
March 12, 2025 - Decision fatigue in hospital settings: a scoping review.
March 12, 2025
Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med.
2024;Epub Nov 11. doi:10.1002/jhm.13550.
https://psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review
Production pressu…
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psnet.ahrq.gov/node/38781/psn-pdf
July 15, 2009 - Medical errors and consequent adverse events in
critically ill surgical patients in a tertiary care teaching
hospital in Delhi.
July 15, 2009
Kumar S, Chaudhary S. Medical errors and consequent adverse events in critically ill surgical patients in a
tertiary care teaching hospital in Delhi. J Emerg Trauma Shock. 2…
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psnet.ahrq.gov/node/39614/psn-pdf
June 18, 2021 - Preventing violence in the health care setting.
June 18, 2021
Preventing violence in the health care setting. Sentinel Event Alert. 2010;(45):1-3.
https://psnet.ahrq.gov/issue/preventing-violence-health-care-setting
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk…
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www.ahrq.gov/funding/process/grant-app-basics/peerprob.html
October 01, 2014 - Common Problems Identified During Peer Review
Below is a list of many common problems that result in non-competitively scored applications.
Uncertainty whether research will produce significant information.
Scientific basis not fully developed.
No apparent translatability of research into practice or po…