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psnet.ahrq.gov/node/44626/psn-pdf
November 04, 2015 - "SWARMing" to improve patient care: a novel approach to
root cause analysis.
November 4, 2015
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause
Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
https://psnet.ahrq.gov/issue/swarming-improve-patient-care-…
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psnet.ahrq.gov/node/48008/psn-pdf
May 22, 2019 - Patients as diagnostic collaborators: sharing visit notes
to promote accuracy and safety.
May 22, 2019
Blease CR, Bell SK. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and
safety. Diagnosis (Berl). 2019;6(3):213-221. doi:10.1515/dx-2018-0106.
https://psnet.ahrq.gov/issue/patients-d…
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psnet.ahrq.gov/node/866587/psn-pdf
January 01, 2025 - Professionalising patient safety? Findings from a mixed-
methods formative evaluation of the patient safety
specialist role in the English National Health Service.
August 28, 2024
Martin G, Pralat R, Waring J, et al. Professionalising patient safety? Findings from a mixed-methods
formative evaluation of the patien…
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psnet.ahrq.gov/node/36577/psn-pdf
January 12, 2011 - Effects of teamwork training on adverse outcomes and
process of care in labor and delivery: a randomized
controlled trial.
January 12, 2011
Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of
care in labor and delivery: a randomized controlled trial. Obstet Gyneco…
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psnet.ahrq.gov/node/37386/psn-pdf
January 06, 2017 - Medication reconciliation in ambulatory oncology.
January 6, 2017
Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual
Patient Saf. 2007;33(12):750-7.
https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology
The Joint Commission mandates systems…
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psnet.ahrq.gov/node/866583/psn-pdf
August 28, 2024 - Assessing the STOPS framework for coping with
intraoperative errors: evidence of efficacy, hints of hubris,
and a bridge to abridging burnout.
August 28, 2024
D'Angelo JD, Rivera M, Rasmussen TE, et al. Assessing the stops framework for coping with intraoperative
errors: evidence of efficacy, hints of hubris, and …
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psnet.ahrq.gov/node/38863/psn-pdf
August 12, 2009 - Use of strategies from high-reliability organisations to the
patient hand-off by resident physicians: practical
implications.
August 12, 2009
Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident
physicians: practical implications. Qual Saf Health Care. 2009;18(4):2…
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psnet.ahrq.gov/node/37499/psn-pdf
January 10, 2017 - Medicare's decision to withhold payment for hospital
errors: the devil is in the details.
January 10, 2017
Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in
the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-23.
https://psnet.ahrq.gov/issue/medicares-deci…
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psnet.ahrq.gov/node/44042/psn-pdf
November 03, 2015 - Deployment of rapid response teams by 31 hospitals in a
statewide collaborative.
November 3, 2015
Stolldorf DP, Jones CB. Deployment of rapid response teams by 31 hospitals in a statewide collaborative.
Jt Comm J Qual Patient Saf. 2015;41(4):186-191.
https://psnet.ahrq.gov/issue/deployment-rapid-response-teams-31-…
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psnet.ahrq.gov/issue/when-doctor-too-old-job
March 04, 2020 - Newspaper/Magazine Article
When is a doctor too old for the job?
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September 18, 2019
Potential deterioration of an aging surgeon's…
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psnet.ahrq.gov/node/60057/psn-pdf
March 18, 2020 - How does the WHO Surgical Safety Checklist fit with
existing perioperative risk management strategies? An
ethnographic study across surgical specialties.
March 18, 2020
Wæhle HV, Haugen AS, Wiig S, et al. How does the WHO Surgical Safety Checklist fit with existing
perioperative risk management strategies? An ethn…
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psnet.ahrq.gov/node/36246/psn-pdf
October 21, 2010 - Tracking rates of patient safety indicators over time:
lessons from the Veterans Administration.
October 21, 2010
Rosen AK, Zhao S, Rivard PE, et al. Tracking rates of Patient Safety Indicators over time: lessons from the
Veterans Administration. Med Care. 2006;44(9):850-61.
https://psnet.ahrq.gov/issue/tracking-r…
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psnet.ahrq.gov/node/72741/psn-pdf
February 17, 2021 - The I-READI quality and safety framework: a health
system’s response to airway complications in
mechanically ventilated patients with Covid-19.
February 17, 2021
Ginestra JC, Atkins JH, Mikkelsen ME, et al. The I-READI Quality and Safety Framework: a health
system’s response to airway complications in mechanically…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/72468/psn-pdf
November 18, 2020 - Development of rapid response capabilities in a large
COVID-19 alternate care site using Failure Modes and
Effect Analysis with in situ simulation.
November 18, 2020
Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19
alternate care site using Failure Modes and Eff…
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psnet.ahrq.gov/node/840153/psn-pdf
November 16, 2022 - Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-wide clinical event debriefing program
and a novel qualitative model to analyze debriefing
content.
November 16, 2022
Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-w…
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psnet.ahrq.gov/node/854818/psn-pdf
October 25, 2023 - The nature, causes, and clinical impact of errors in the
clinical laboratory testing process leading to diagnostic
error: a voluntary incident report analysis.
October 25, 2023
van Moll C, Egberts TCG, Wagner C, et al. The nature, causes, and clinical impact of errors in the clinical
laboratory testing process lea…
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psnet.ahrq.gov/node/50824/psn-pdf
January 22, 2020 - Failure to rescue and 30-day in-hospital mortality in
hospitals with and without crew-resource-management
safety training.
January 22, 2020
Bacon CT, McCoy TP, Henshaw DS. Failure to rescue and 30?day in?hospital mortality in hospitals with
and without crew?resource?management safety training. Res Nurs Health. 201…
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psnet.ahrq.gov/node/48143/psn-pdf
January 01, 2020 - Assessing the safety of electronic health records: a
national longitudinal study of medication-related decision
support.
August 7, 2019
Holmgren J, Co Z, Newmark L, et al. Assessing the safety of electronic health records: a national
longitudinal study of medication-related decision support. BMJ Qual Saf. 2020;29(…
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psnet.ahrq.gov/node/72774/psn-pdf
February 24, 2021 - Preventable adverse drug events causing hospitalisation:
identifying root causes and developing a surveillance and
learning system at an urban community hospital, a cross-
sectional observational study.
February 24, 2021
de Lemos J, Loewen PS, Nagle C, et al. Preventable adverse drug events causing hospitalisation…