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psnet.ahrq.gov/issue/transition-care-hospitalized-elderly-patients-development-discharge-checklist-hospitalists
November 16, 2022 - Commentary
Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.
Citation Text:
Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists…
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psnet.ahrq.gov/issue/rx-medication-errors
July 19, 2023 - Newspaper/Magazine Article
Rx for medication errors.
Citation Text:
Friedley NJC. Rx for medication errors. A patient medication safety plan can help prevent the cascade of devastating and preventable complications from adverse drug events. Medical economics. 2008;85(20):34-8.
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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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DOI Google S…
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psnet.ahrq.gov/issue/quality-improvement-and-patient-care-checklists-intrahospital-transfers-involving-pediatric
September 23, 2020 - Study
Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.
Citation Text:
Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.…
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety-framework-mmsf-learning-its-implementation-canada
September 24, 2018 - Commentary
Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.
Citation Text:
Carthey J. Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. BMJ Qual Saf. 2023;32(8):441-443. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - designed in a way that you could say, “Of these components of a
complex intervention, three must be implemented
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psnet.ahrq.gov/node/46233/psn-pdf
September 24, 2017 - Cutting-edge efforts in surgical patient safety.
September 24, 2017
Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719-
720. doi:10.1001/jamasurg.2017.0858.
https://psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
Implementation science examines me…
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psnet.ahrq.gov/node/34036/psn-pdf
March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004.
March 28, 2005
Department of Veterans Affairs (VA) National Center for Patient Safety
https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
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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/submit-your-toolkit-landing
Breadcrumb
Home
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/847057/psn-pdf
April 05, 2023 - Implement strategies to prevent persistent medication
errors and hazards.
April 5, 2023
ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
Medication mistakes are recognized contributors to p…
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psnet.ahrq.gov/node/38889/psn-pdf
April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a
laboratory physician order entry system implementation.
April 1, 2010
Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory
physician order entry system implementation. Int J Med Inform. 2010;79(4):e58-70.
doi:…
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psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - Implement strategies to prevent persistent medication
errors and hazards: 2024.
April 3, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack of p…
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psnet.ahrq.gov/node/50875/psn-pdf
February 05, 2020 - Implementing Closing the Loop. Safe Practices for
Diagnostic Results
February 5, 2020
Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
Health information technology (HIT) can improve record keepi…
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psnet.ahrq.gov/node/42355/psn-pdf
February 11, 2015 - Advancing Successful Care Transitions to Improve
Outcomes.
February 11, 2015
Society of Hospital Medicine
https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program
This Web site provides resources associated with the Better Outcomes for Older adults through Safe
Transitions project, called Projec…
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psnet.ahrq.gov/issue/improving-code-team-performance-and-survival-outcomes-implementation-pediatric-resuscitation
February 03, 2011 - Study
Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training.
Citation Text:
Knight LJ, Gabhart JM, Earnest KS, et al. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. C…
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psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
November 16, 2022 - Study
The Human Factors Analysis Classification System (HFACS) applied to health care.
Citation Text:
Diller T, Helmrich G, Dunning S, et al. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623. …
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psnet.ahrq.gov/issue/structured-patient-handoff-internal-medicine-ward-cluster-randomized-control-trial
September 23, 2020 - Study
Structured patient handoff on an internal medicine ward: a cluster randomized control trial.
Citation Text:
Tam P, Nijjar AP, Fok M, et al. Structured patient handoff on an internal medicine ward: A cluster randomized control trial. PLoS One. 2018;13(4):e0195216. doi:10.1371/journa…
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psnet.ahrq.gov/issue/risk-managers-descriptions-programs-support-second-victims-after-adverse-events
May 11, 2016 - Study
Risk managers' descriptions of programs to support second victims after adverse events.
Citation Text:
White AA, Brock DM, McCotter PI, et al. Risk managers' descriptions of programs to support second victims after adverse events. J Healthc Risk Manag. 2015;34(4):30-40. doi:10.1002…
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psnet.ahrq.gov/issue/use-second-victim-experience-and-support-tool-svest-assess-impact-departmental-peer-support
December 23, 2020 - Study
Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.
Citation Text:
Use of the Second Victim …