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psnet.ahrq.gov/node/42931/psn-pdf
April 20, 2014 - Assigning a team-based pager for on-call physicians
reduces paging errors in a large academic hospital.
April 20, 2014
Shieh L, Chi J, Kulik C, et al. Assigning a team-based pager for on-call physicians reduces paging errors in
a large academic hospital. Jt Comm J Qual Patient Saf. 2014;40(2):77-82.
https://psnet.…
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psnet.ahrq.gov/node/46374/psn-pdf
August 30, 2017 - Structured patient handoffs: the movement toward
adverse event reduction in the perioperative unit.
August 30, 2017
Hamilton WL.
https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction-
perioperative-unit
Miscommunication during care transitions can contribute to medical e…
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psnet.ahrq.gov/node/866160/psn-pdf
June 19, 2024 - Checking all the boxes: a checklist for when and how to
use checklists effectively.
June 19, 2024
Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use
checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bmjqs-2023-016934.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47601/psn-pdf
December 21, 2018 - Clinical decision support in the era of artificial
intelligence.
December 21, 2018
Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA.
2018;320(21):2199-2200. doi:10.1001/jama.2018.17163.
https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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psnet.ahrq.gov/node/46866/psn-pdf
May 23, 2018 - Improving maternal safety at scale with the mentor model
of collaborative improvement.
May 23, 2018
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of
Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259.
doi:10.1016/j.jcjq.2017.11.005.
https://psn…
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psnet.ahrq.gov/node/48045/psn-pdf
June 05, 2019 - Obstetric practice guidelines: labor's love lost?
June 5, 2019
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med.
2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
Guidelines play a…
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psnet.ahrq.gov/node/46901/psn-pdf
May 30, 2018 - Physician resiliency and wellness for transforming a
health system.
May 30, 2018
Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018.
https://psnet.ahrq.gov/issue/physician-resiliency-and-wellness-transforming-health-system
Physician burnout can contribute to medical errors. This article discusses an organizational e…
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psnet.ahrq.gov/node/45234/psn-pdf
November 18, 2016 - Recommended responsibilities for management of MR
safety.
November 18, 2016
Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J
Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282.
https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
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psnet.ahrq.gov/node/40305/psn-pdf
March 23, 2011 - Effect of a comprehensive obstetric patient safety
program on compensation payments and sentinel events.
March 23, 2011
Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on
compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204(2):97-105.
doi:10.1016/…
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psnet.ahrq.gov/node/40672/psn-pdf
September 03, 2011 - Didactic and simulation nontechnical skills team training
to improve perinatal patient outcomes in a community
hospital.
September 3, 2011
Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve
perinatal patient outcomes in a community hospital. Jt Comm J Qual Pat…
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psnet.ahrq.gov/node/42116/psn-pdf
March 20, 2013 - Rapid response systems as a patient safety strategy: a
systematic review.
March 20, 2013
Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051-00009.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/34061/psn-pdf
January 04, 2017 - Patient Safety Leadership WalkRounds.
January 4, 2017
Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf.
2003;29(1). doi:10.1016/s1549-3741(03)29003-1.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds
This study shares the concept of an interventi…
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psnet.ahrq.gov/node/43967/psn-pdf
November 16, 2015 - Equipped: overcoming barriers to change to improve
quality of care (theories of change).
November 16, 2015
Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of
care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-8. doi:10.1136/archdischild-2013-
…
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psnet.ahrq.gov/node/867700/psn-pdf
March 01, 2023 - Toolkit for Reducing Central Line-Associated Blood
Stream Infections.
March 1, 2023
Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream
Infections. March 2023.
https://psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections
Eliminatin…
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psnet.ahrq.gov/node/72828/psn-pdf
March 10, 2021 - A recurring call to action: every healthcare organization
needs a medication safety officer!
March 10, 2021
ISMP Medication Safety Alert! Acute care edition. February 25, 2021;26(4);1-4.
https://psnet.ahrq.gov/issue/recurring-call-action-every-healthcare-organization-needs-medication-safety-
officer
Leadership ro…
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psnet.ahrq.gov/node/848383/psn-pdf
May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in
Your Practice.
May 3, 2023
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2023. AHRQ Publication No. 23-0025.
https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
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psnet.ahrq.gov/node/60929/psn-pdf
September 16, 2020 - Safer Together: A National Action Plan to Advance Patient
Safety.
September 16, 2020
Boston, MA: Institute for Healthcare Improvement: September 2020.
https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety
This National Action Plan developed by the National Steering Committee for Pati…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…