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psnet.ahrq.gov/node/838925/psn-pdf
March 03, 2025 - Improving Quality and Safety in Healthcare.
March 3, 2025
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2025.
https://psnet.ahrq.gov/issue/improving-quality-and-safety-healthcare
Improvement activities are complex initiatives that require synergistic actions by organizations to be
s…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - Theirs was a three-phase intervention that
implemented a team training program, unit-based safety teams
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psnet.ahrq.gov/node/47662/psn-pdf
February 21, 2024 - Lucian Leape Patient Safety Fellowship Award.
February 21, 2024
International Society for Quality in Health Care
https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award
Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop
physicians and leaders see…
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psnet.ahrq.gov/node/837811/psn-pdf
August 10, 2022 - Examining the Status of VA’s Electronic Health Record
Modernization Program.
August 10, 2022
US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).
https://psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program
Large-scale electronic health record (EHR) …
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psnet.ahrq.gov/node/47246/psn-pdf
September 19, 2018 - Implementing Optimal Team-Based Care to Reduce
Clinician Burnout.
September 19, 2018
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2018.
https://psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
Teamwork can contribute to a h…
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psnet.ahrq.gov/node/44407/psn-pdf
April 15, 2016 - Frequency and severity of parenteral nutrition medication
errors at a large children's hospital after implementation
of electronic ordering and compounding.
April 15, 2016
MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors
at a Large Children's Hospital After Im…
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psnet.ahrq.gov/submit-your-toolkit-landing
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Improvement Resources
Toolkits
Toolkit Submissions
PSNet encourages healthcare-related organizations to help make care safer by submitting a Patient Safety Toolkit to support the implementation of products, services, processes, systems, policies, organizational stru…
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psnet.ahrq.gov/node/42083/psn-pdf
March 13, 2013 - The top patient safety strategies that can be encouraged
for adoption now.
March 13, 2013
Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for
adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-5-201303051-00001.
https://psnet.ahrq.go…
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psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma
March 07, 2018 - Study
Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.
Citation Text:
Howie WO, Dutton RP. Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot…
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psnet.ahrq.gov/issue/medication-discrepancies-pediatric-hospital-discharge
January 29, 2020 - Study
Medication discrepancies at pediatric hospital discharge.
Citation Text:
Gattari TB, Krieger LN, Hu HM, et al. Medication Discrepancies at Pediatric Hospital Discharge. Hosp Pediatr. 2015;5(8):439-45. doi:10.1542/hpeds.2014-0085.
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psnet.ahrq.gov/issue/preventing-medication-errors-information-age
February 15, 2023 - Commentary
Preventing medication errors in the information age.
Citation Text:
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-58. doi:10.1097/01.NURSE.0000544230.51598.38.
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psnet.ahrq.gov/issue/changing-operating-room-culture-implementation-postoperative-debrief-and-improved-safety
December 03, 2014 - Study
Changing operating room culture: implementation of a postoperative debrief and improved safety culture.
Citation Text:
Magill ST, Wang DD, Rutledge C, et al. Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture. World Neurosurg. 201…
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psnet.ahrq.gov/issue/eliminating-perioperative-adverse-events-ascension-health
November 16, 2022 - Commentary
Eliminating perioperative adverse events at Ascension Health.
Citation Text:
Ewing H, Bruder G, Baroco P, et al. Eliminating perioperative adverse events at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(5):256-66.
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psnet.ahrq.gov/issue/using-standardized-or-checklists-and-creating-extended-time-out-checklists
February 15, 2011 - Commentary
Using standardized OR checklists and creating extended time-out checklists.
Citation Text:
Hey LA, Turner TC. Using Standardized OR Checklists and Creating Extended Time-Out Checklists. AORN J. 2016;104(3):248-53. doi:10.1016/j.aorn.2016.07.007.
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psnet.ahrq.gov/issue/always-having-say-youre-sorry-ethical-response-making-mistakes-professional-practice
September 09, 2011 - Review
Always having to say you're sorry: an ethical response to making mistakes in professional practice.
Citation Text:
Crigger NJ. Always having to say you're sorry: an ethical response to making mistakes in professional practice. Nurs Ethics. 2004;11(6):568-76.
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psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
October 19, 2022 - Commentary
Preparing challenging medications for barcode scanning.
Citation Text:
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454.
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psnet.ahrq.gov/issue/adapting-joint-commissions-seven-foundations-safe-and-effective-transitions-care-home
July 10, 2024 - Commentary
Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home.
Citation Text:
Labson MC. Adapting the joint commission's seven foundations of safe and effective transitions of care to home. Home Healthc Now. 2015;33(3):142-6. doi:10.1097/N…
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psnet.ahrq.gov/issue/next-phase-health-care-improvement-what-can-we-learn-social-movements
July 22, 2010 - Commentary
The next phase of health care improvement: what can we learn from social movements?
Citation Text:
Bate P, Robert G, Bevan H. The next phase of healthcare improvement: what can we learn from social movements? Qual Saf Health Care. 2004;13(1):62-6.
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psnet.ahrq.gov/issue/barriers-implementation-patient-safety-systems-healthcare-institutions-leadership-and-policy
July 14, 2010 - Study
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications.
Citation Text:
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. Akins RB, Cole BR. J Patient …
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psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
March 04, 2020 - Study
Finding blunders in thyroid testing: experience in newborns.
Citation Text:
Zilka LJ, Lott JA, Baker LC, et al. Finding blunders in thyroid testing: experience in newborns. J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247.
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