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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/46682/psn-pdf
January 24, 2018 - AHRQ Safety Program for Surgery.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No.
16(18)-0004-1-EF.
https://psnet.ahrq.gov/issue/ahrq-safety-program-surgery
Large-scale collaboratives have achieved success in implementing patient safety improvements. T…
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psnet.ahrq.gov/node/44640/psn-pdf
February 20, 2016 - The problem with Plan-Do-Study-Act cycles.
February 20, 2016
Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52.
doi:10.1136/bmjqs-2015-005076.
https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles
Rapid-cycle improvement methods have been embraced as an approach t…
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psnet.ahrq.gov/node/43633/psn-pdf
November 05, 2014 - An integrative review: fatigue among nurses in acute care
settings.
November 5, 2014
Smith-Miller CA, Shaw-Kokot J, Curro B, et al. An integrative review: fatigue among nurses in acute care
settings. J Nurs Adm. 2014;44(9):487-94. doi:10.1097/NNA.0000000000000104.
https://psnet.ahrq.gov/issue/integrative-review-fa…
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psnet.ahrq.gov/node/38725/psn-pdf
November 23, 2016 - A new structure of attention? Open disclosure of adverse
events to patients and their families.
November 23, 2016
Iedema R, Jorm C, Wakefield JG, et al. A New Structure of Attention? J Lang Soc Psychol. 2009;28(2).
doi:10.1177/0261927x08330614.
https://psnet.ahrq.gov/issue/new-structure-attention-open-disclosure-a…
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psnet.ahrq.gov/node/60227/psn-pdf
April 15, 2020 - The next step in learning from sentinel events in
healthcare.
April 15, 2020
Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare.
BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739.
https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…
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psnet.ahrq.gov/node/43298/psn-pdf
June 25, 2014 - Electronic prescribing: improving the efficiency and
accuracy of prescribing in the ambulatory care setting.
June 25, 2014
Porterfield A, Engelbert K, Coustasse A. Electronic prescribing: improving the efficiency and accuracy of
prescribing in the ambulatory care setting. Perspect Health Inf Manag. 2014;11:1g.
htt…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Importantly, the design and usability of tools and technologies—including how they are implemented by
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psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - The clinic had just implemented electronic prescribing—the ability to electronically transmit a
new
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psnet.ahrq.gov/node/37883/psn-pdf
July 02, 2008 - The limits of knowledge management for UK public
services modernization: the case of patient safety and
service quality.
July 2, 2008
Currie G, Waring J, Finn R. THE LIMITS OF KNOWLEDGE MANAGEMENT FOR UK PUBLIC SERVICES
MODERNIZATION: THE CASE OF PATIENT SAFETY AND SERVICE QUALITY. Public Adm. 2008;86(2).
doi:10.…
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psnet.ahrq.gov/node/60954/psn-pdf
September 30, 2020 - Catheter-associated urinary tract infection reduction in a
pediatric safety engagement network.
September 30, 2020
Foster CB, Ackerman K, Hupertz V, et al. Catheter-associated urinary tract infection reduction in a pediatric
safety engagement network. Pediatrics. 2020;146(4):e20192057. doi:10.1542/peds.2019-2057.
…
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psnet.ahrq.gov/node/838921/psn-pdf
October 26, 2022 - Improving discharge safety in a pediatric emergency
department.
October 26, 2022
Paydar-Darian N, Stack AM, Volpe D, et al. Improving discharge safety in a pediatric emergency
department. Pediatrics. 2022;150(5):e2021054307. doi:10.1542/peds.2021-054307.
https://psnet.ahrq.gov/issue/improving-discharge-safety-pedi…
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psnet.ahrq.gov/node/74094/psn-pdf
November 17, 2021 - Workplace Safety Supplemental Item Set for Hospital
SOPS.
November 17, 2021
Rockville, MD: Agency for Healthcare Research and Quality; 2021.
https://psnet.ahrq.gov/issue/workplace-safety-supplemental-item-set-hospital-sops
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patie…
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psnet.ahrq.gov/node/38027/psn-pdf
October 15, 2008 - Assessing the Evidence Base for Context-Sensitive
Effectiveness and Safety of Patient Safety Practices:
Developing Criteria.
October 15, 2008
US Department of Health and Human Services; HHS; Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/assessing-evidence-base-context-sensitive-eff…
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psnet.ahrq.gov/node/60664/psn-pdf
July 08, 2020 - Applying the Medications at Transitions and Clinical
Handoffs Toolkit in a rural primary care clinic:
implications for nursing, patients, and caregivers.
July 8, 2020
Jarrett T, Cochran J, Baus A. Applying the Medications at Transitions and Clinical Handoffs Toolkit in a
rural primary care clinic: implications for…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/46651/psn-pdf
January 17, 2018 - Piloting a patient safety and quality improvement co-
curriculum.
January 17, 2018
Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co-
curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357.
doi:10.1080/20009666.2017.1403830.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43143/psn-pdf
April 25, 2016 - Surgical programs in the Veterans Health Administration
maintain briefing and debriefing following medical team
training.
April 25, 2016
West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing
and debriefing following medical team training. Jt Comm J Qual Patient…
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psnet.ahrq.gov/node/36829/psn-pdf
March 28, 2011 - Confidential reporting of patient safety events in primary
care: results from a multilevel classification of cognitive
and system factors.
March 28, 2011
Kostopoulou O, Delaney B. Confidential reporting of patient safety events in primary care: results from a
multilevel classification of cognitive and system facto…
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psnet.ahrq.gov/node/45908/psn-pdf
April 05, 2017 - Towards a framework for managing risk associated with
technology-induced error.
April 5, 2017
Borycki EM, Kushniruk AW. Towards a Framework for Managing Risk Associated with Technology-Induced
Error. Stud Health Technol Inform. 2017;234:42-48.
https://psnet.ahrq.gov/issue/towards-framework-managing-risk-associated…