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psnet.ahrq.gov/node/39505/psn-pdf
November 26, 2014 - Improving teamwork: impact of structured
interdisciplinary rounds on a medical teaching unit.
November 26, 2014
O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds
on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. doi:10.1007/s11606-010-1345-6.
h…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
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psnet.ahrq.gov/node/39498/psn-pdf
February 10, 2015 - The effect of health information technology on quality in
U.S. hospitals.
February 10, 2015
McCullough JS, Casey M, Moscovice I, et al. The effect of health information technology on quality in U.S.
hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155.
https://psnet.ahrq.gov/issue/ef…
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psnet.ahrq.gov/node/42880/psn-pdf
January 22, 2014 - Applying ethnography to the study of context in
healthcare quality and safety.
January 22, 2014
Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality
and safety. BMJ Qual Saf. 2014;23(2):99-105. doi:10.1136/bmjqs-2013-002335.
https://psnet.ahrq.gov/issue/applyin…
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psnet.ahrq.gov/node/36367/psn-pdf
April 11, 2011 - Emergency medical services system changes reduce
pediatric epinephrine dosing errors in the prehospital
setting.
April 11, 2011
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric
epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…
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psnet.ahrq.gov/node/42128/psn-pdf
August 15, 2013 - Computerized prescriber order entry and opportunities
for medication errors: comparison to tradition paper-
based order entry.
August 15, 2013
Jozefczyk KG, Kennedy WK, Lin MJ, et al. Computerized prescriber order entry and opportunities for
medication errors: comparison to tradition paper-based order entry. J Pha…
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psnet.ahrq.gov/node/844553/psn-pdf
February 15, 2023 - Mental health conditions leading cause of pregnancy-
related deaths.
February 15, 2023
Quick Safety. January 16 2023;(67):1-3.
https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths
Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…
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psnet.ahrq.gov/node/39458/psn-pdf
April 12, 2011 - Hospital admission medication reconciliation in medically
complex children: an observational study.
April 12, 2011
Stone BL, Boehme S, Mundorff MB, et al. Hospital admission medication reconciliation in medically
complex children: an observational study. Arch Dis Child. 2009. doi:10.1136/adc.2009.167528.
https://p…
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psnet.ahrq.gov/node/45927/psn-pdf
April 12, 2017 - How redesigning the abrasive alarms of hospital
soundscapes can save lives.
April 12, 2017
Couch C. Fast Company. April 3, 2017.
https://psnet.ahrq.gov/issue/how-redesigning-abrasive-alarms-hospital-soundscapes-can-save-lives
Alarm frequency can contribute to distractions and stress in the hospital environment. Re…
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psnet.ahrq.gov/node/35485/psn-pdf
May 27, 2011 - Navigating the information technology highway:
computer solutions to reduce errors and enhance patient
safety.
May 27, 2011
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance
patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45933/psn-pdf
March 08, 2017 - Bad hospital design is making us sicker.
March 8, 2017
Khullar D. New York Times. February 22, 2017.
https://psnet.ahrq.gov/issue/bad-hospital-design-making-us-sicker
Implementing design changes in care environments can improve patient safety. This newspaper article
reports on how efforts to address hospital desig…
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psnet.ahrq.gov/node/46043/psn-pdf
April 05, 2017 - High-reliability and the I-PASS communication tool.
April 5, 2017
Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse).
2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5.
https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool
High reliability has y…
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psnet.ahrq.gov/node/47512/psn-pdf
February 20, 2019 - Framing the challenges of artificial intelligence in
medicine.
February 20, 2019
Yu K-H, Kohane IS. Framing the challenges of artificial intelligence in medicine. BMJ Qual Saf.
2019;28(3):238-241. doi:10.1136/bmjqs-2018-008551.
https://psnet.ahrq.gov/issue/framing-challenges-artificial-intelligence-medicine
Use o…
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psnet.ahrq.gov/node/39898/psn-pdf
February 01, 2011 - Improving reliability of clinical care practices for
ventilated patients in the context of a patient safety
improvement initiative.
February 1, 2011
Pinto A, Burnett S, Benn J, et al. Improving reliability of clinical care practices for ventilated patients in the
context of a patient safety improvement initiative.…
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psnet.ahrq.gov/node/38211/psn-pdf
May 21, 2009 - Effectiveness of a barcode medication administration
system in reducing preventable adverse drug events in a
neonatal intensive care unit: a prospective cohort study.
May 21, 2009
Morriss FH, Abramowitz PW, Nelson S, et al. Effectiveness of a barcode medication administration system
in reducing preventable adverse…
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psnet.ahrq.gov/node/40235/psn-pdf
May 11, 2011 - Assessing and improving safety climate in a large cohort
of intensive care units.
May 11, 2011
Sexton B, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of
intensive care units. Crit Care Med. 2011;39(5):934-9. doi:10.1097/CCM.0b013e318206d26c.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41969/psn-pdf
July 02, 2014 - The creation and impact of a dedicated section on quality
and patient safety in a clinical academic department.
July 2, 2014
Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety
in a Clinical Academic Department. Academic Medicine. 2012;88(2). doi:10.1097/acm.0b013e3…
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psnet.ahrq.gov/node/36226/psn-pdf
August 30, 2006 - Framework for a High Performance Health System for the
United States.
August 30, 2006
Mongan JJ. New York, NY; The Commonwealth Fund: 2006.
https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states
This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
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psnet.ahrq.gov/node/74143/psn-pdf
December 01, 2021 - Confronting Racism in Health Care: Moving from
Proclamations to New Practices.
December 1, 2021
Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021
https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
Structural racism affects the safety and equit…
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…