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psnet.ahrq.gov/node/836748/psn-pdf
March 16, 2022 - Analysis of the interprofessional clinical learning
environment for quality improvement and patient safety
from perspectives of interprofessional teams.
March 16, 2022
Cheng MKW, Collins S, Baron RB, et al. Analysis of the interprofessional clinical learning environment for
quality improvement and patient safety f…
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psnet.ahrq.gov/node/34829/psn-pdf
April 06, 2011 - Use of medical emergency team responses to reduce
hospital cardiopulmonary arrests.
April 6, 2011
Devita MA, Braithwaite RS, Mahidhara R, et al. Use of medical emergency team responses to reduce
hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251-4.
https://psnet.ahrq.gov/issue/use-medical-emerg…
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psnet.ahrq.gov/node/60869/psn-pdf
September 02, 2020 - A systematic review of trauma crew resource
management training: what can the United States and the
United Kingdom learn from each other?
September 2, 2020
Ashcroft J, Wilkinson A, Khan M. A systematic review of trauma crew resource management training: what
can the United States and the United Kingdom learn from …
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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - Lost in translation: challenges and opportunities in
physician-to-physician communication during patient
handoffs.
August 5, 2009
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-
physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.
…
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psnet.ahrq.gov/node/45365/psn-pdf
August 03, 2016 - Workarounds and test results follow-up in electronic
health record–based primary care.
August 3, 2016
Menon S, Murphy DR, Singh H, et al. Workarounds and Test Results Follow-up in Electronic Health
Record-Based Primary Care. Appl Clin Inform. 2016;7(2):543-559. doi:10.4338/ACI-2015-10-RA-0135.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/860722/psn-pdf
January 17, 2024 - Ten years of incident reports on in-hospital cardiac arrest
- Are they useful for improvements?
January 17, 2024
Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements?
Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525.
https://psnet.ahrq.gov/issue/ten-y…
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psnet.ahrq.gov/node/838321/psn-pdf
October 12, 2022 - Meeting the Moment: Addressing Barriers and Facilitating
Clinical Adoption of Artificial Intelligence in Medical
Diagnosis.
October 12, 2022
Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2022.
https://psnet.ahrq.gov/issue/meeting-moment-addressing-bar…
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psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - Advancing perinatal patient safety through application of
safety science principles using health IT.
April 4, 2018
Webb J, Sorensen A, Sommerness SA, et al. Advancing perinatal patient safety through application of
safety science principles using health IT. BMC Med Inform Decis Mak. 2017;17(1):176.
doi:10.1186/s12…
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psnet.ahrq.gov/node/47374/psn-pdf
April 07, 2019 - Developing a conceptual framework for patient safety
culture in emergency department: a review of the
literature.
April 7, 2019
Alshyyab MA, FitzGerald G, Dingle K, et al. Developing a conceptual framework for patient safety culture in
emergency department: A review of the literature. Int J Health Plann Manage. 20…
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psnet.ahrq.gov/node/45851/psn-pdf
February 22, 2017 - Eight years of decreased methicillin-resistant
Staphylococcus aureus health care–associated infections
associated with a Veterans Affairs prevention initiative.
February 22, 2017
Evans ME, Kralovic SM, Simbartl LA, et al. Eight years of decreased methicillin-resistant Staphylococcus
aureus health care-associated i…
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psnet.ahrq.gov/node/72657/psn-pdf
January 20, 2021 - Establishing a multi-institutional quality and patient
safety consortium: collaboration across affiliates in a
community-based medical school.
January 20, 2021
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium:
collaboration across affiliates in a commun…
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psnet.ahrq.gov/node/44507/psn-pdf
July 18, 2016 - Six habits to enhance MET performance under stress: a
discussion paper reviewing team mechanisms for
improved patient outcomes.
July 18, 2016
Fein EC, Mackie B, Chernyak-Hai L, et al. Six habits to enhance MET performance under stress: A
discussion paper reviewing team mechanisms for improved patient outcomes. Aus…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/45876/psn-pdf
January 01, 2021 - Making residents part of the safety culture: improving
error reporting and reducing harms.
February 15, 2017
Fox MD, Bump GM, Butler GA, et al. Making Residents Part of the Safety Culture: Improving Error
Reporting and Reducing Harms. J Patient Saf. 2021;17(5):e373-e378.
doi:10.1097/PTS.0000000000000344.
https://…
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psnet.ahrq.gov/node/47910/psn-pdf
August 21, 2019 - Cognitive Informatics: Reengineering Clinical Workflow
for Safer and More Efficient Care.
August 21, 2019
Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publishing; 2019. ISBN:
9783030169152.
https://psnet.ahrq.gov/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-…
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psnet.ahrq.gov/node/34067/psn-pdf
January 04, 2017 - Does full disclosure of medical errors affect malpractice
liability? The jury is still out.
January 4, 2017
Kachalia A, Shojania KG, Hofer TP, et al. Does full disclosure of medical errors affect malpractice liability?
The jury is still out. Jt Comm J Qual Saf. 2003;29(10):503-11.
https://psnet.ahrq.gov/issue/does…
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psnet.ahrq.gov/node/47993/psn-pdf
May 15, 2019 - Using near-miss events to improve MRI safety in a large
academic centre.
May 15, 2019
Goolsarran N, Martinez J, Garcia C. Using near-miss events to improve MRI safety in a large academic
centre. BMJ Open Qual. 2019;8(2):e000593. doi:10.1136/bmjoq-2018-000593.
https://psnet.ahrq.gov/issue/using-near-miss-events-imp…
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psnet.ahrq.gov/node/45510/psn-pdf
October 19, 2016 - How to perform a root cause analysis for workup and
future prevention of medical errors: a review.
October 19, 2016
Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future
prevention of medical errors: a review. Patient Saf Surg. 2016;10:20. doi:10.1186/s13037-016-0107-8.
…
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psnet.ahrq.gov/node/40025/psn-pdf
December 21, 2014 - Evaluating an evidence-based bundle for preventing
surgical site infection.
December 21, 2014
Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical
site infection: a randomized trial. Arch Surg. 2011;146(3):263-9. doi:10.1001/archsurg.2010.249.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/866596/psn-pdf
August 28, 2024 - Electronic Test Result Communication in the Era of the
21st Century Cures Act
August 28, 2024
Bradford A, Ehsan S, Shahid U, et al. Electronic Test Result Communication In The Era Of The 21St
Century Cures Act. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. AHRQ
Publication No. 24-0010-3-EF
…