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psnet.ahrq.gov/node/60755/psn-pdf
August 05, 2020 - Patient safety from executive hospital management to
wards: a qualitative study identifying factors influencing
implementation.
August 5, 2020
Conner T, Unsworth J, Machin A. Patient safety from executive hospital management to wards: a
qualitative study identifying factors influencing implementation. J Nurs Manag…
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psnet.ahrq.gov/node/46749/psn-pdf
April 04, 2018 - Toolkit for Improving Perinatal Safety.
April 4, 2018
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
https://psnet.ahrq.gov/issue/toolkit-improving-perinatal-safety
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from
comprehensive unit-based safe…
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psnet.ahrq.gov/node/851918/psn-pdf
August 02, 2023 - Racism in health services for adolescents: a scoping
review.
August 2, 2023
Hilario C, Louie-Poon S, Taylor M, et al. Racism in health services for adolescents: a scoping review. Int J
Soc Determinants Health Health Serv. 2023;53(3):343-353. doi:10.1177/27551938231162560.
https://psnet.ahrq.gov/issue/racism-health…
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digital.ahrq.gov/sites/default/files/docs/page/7_StakeholderMeetingChecklist_1.pdf
June 16, 2021 - 7_StakeholderMeetingChecklist
Tool 7. Stakeholder Meeting Checklist
Tool 7. Stakeholder Meeting Checklist
Supplies
Laptop Extra batteries
Tape recorder Debriefing form
Tapes (90 min) Watch or clock
Microphone Speaker phone
Table tents Conference line
Magic markers White board and marker…
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psnet.ahrq.gov/node/866967/psn-pdf
October 16, 2024 - Placing patient safety at the heart of value-based
healthcare.
October 16, 2024
La Regina M, Federici L, Bianco A, et al. Placing patient safety at the heart of value-based healthcare. Int J
Qual Health Care. 2024;36(3):mzae087. doi:10.1093/intqhc/mzae087.
https://psnet.ahrq.gov/issue/placing-patient-safety-heart-…
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psnet.ahrq.gov/node/47167/psn-pdf
May 30, 2018 - AHRQ Health Information Technology Division's 2017
Annual Report.
May 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-
EF.
https://psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
Health care has worked to enhance use…
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psnet.ahrq.gov/node/45298/psn-pdf
April 22, 2017 - The problem with root cause analysis.
April 22, 2017
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-
422. doi:10.1136/bmjqs-2016-005511.
https://psnet.ahrq.gov/issue/problem-root-cause-analysis
Root cause analysis (RCA) is a strategy to investigate incident…
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psnet.ahrq.gov/node/44821/psn-pdf
December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient
Safety Culture.
December 5, 2022
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November
2022. AHRQ Publication No. 23-0011.
https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
Im…
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psnet.ahrq.gov/node/45016/psn-pdf
April 27, 2016 - Medication safety systems and the important role of
pharmacists.
April 27, 2016
Mansur JM. Medication Safety Systems and the Important Role of Pharmacists. Drugs Aging.
2016;33(3):213-21. doi:10.1007/s40266-016-0358-1.
https://psnet.ahrq.gov/issue/medication-safety-systems-and-important-role-pharmacists
Preventin…
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psnet.ahrq.gov/node/37924/psn-pdf
December 23, 2016 - Behaviors that undermine a culture of safety.
December 23, 2016
Behaviors that undermine a culture of safety. Sentinel event alert. 2008;(40):1-3.
https://psnet.ahrq.gov/issue/behaviors-undermine-culture-safety
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk…
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psnet.ahrq.gov/node/844059/psn-pdf
February 08, 2023 - Misdiagnosis in the emergency department: time for a
system solution.
February 8, 2023
Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA.
2023;329(8):631-632. doi:10.1001/jama.2023.0577.
https://psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solu…
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psnet.ahrq.gov/node/838927/psn-pdf
October 26, 2022 - Survey results from pharmacists provide support to
enhance the organizational response to codes.
October 26, 2022
ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.
https://psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-
codes
Patient res…
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psnet.ahrq.gov/node/47737/psn-pdf
March 06, 2019 - Quality improvement and safety in pediatric emergency
medicine.
March 6, 2019
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine.
Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/73481/psn-pdf
July 07, 2021 - Leadership To Improve Diagnosis: A Call to Action.
July 7, 2021
Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality;
June 2021. AHRQ Publication No. 20(21)-0040-5-EF.
https://psnet.ahrq.gov/issue/leadership-improve-diagnosis-call-action
The mindset on diagnostic error…
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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/865681/psn-pdf
April 24, 2024 - DOD Should Improve Its Process for Clinical Adverse
Actions against Providers.
April 24, 2024
Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-
106107.
https://psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
Health care o…
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psnet.ahrq.gov/node/44250/psn-pdf
November 09, 2015 - An evaluation of hand hygiene in an intensive care unit:
are visitors a potential vector for pathogens?
November 9, 2015
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. An evaluation of hand hygiene in an intensive care unit: Are
visitors a potential vector for pathogens? J Infect Public Health. 2015;8(6):570-4.
doi:…
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psnet.ahrq.gov/node/47878/psn-pdf
June 05, 2019 - Nursing practice with hospitalised older people: safety
and harm.
June 5, 2019
Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalised older people: Safety and harm. Int J
Older People Nurs. 2019;14(1):e12220. doi:10.1111/opn.12220.
https://psnet.ahrq.gov/issue/nursing-practice-hospitalised-older-people…
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psnet.ahrq.gov/node/856633/psn-pdf
January 01, 2024 - Digital health intervention on patient safety for children
and parents: a scoping review.
November 29, 2023
Park J, Jeon H, Choi EK. Digital health intervention on patient safety for children and parents: a scoping
review. J Adv Nurs. 2024;80(5):1750-1760. doi:10.1111/jan.15954.
https://psnet.ahrq.gov/issue/digita…