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psnet.ahrq.gov/node/42906/psn-pdf
February 27, 2014 - From heroism to safe design: leveraging technology.
February 27, 2014
Pronovost P, Bo-Linn GW, Sapirstein A. From heroism to safe design: leveraging technology.
Anesthesiology. 2014;120(3):526-9. doi:10.1097/ALN.0000000000000127.
https://psnet.ahrq.gov/issue/heroism-safe-design-leveraging-technology
This commentar…
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psnet.ahrq.gov/node/40906/psn-pdf
November 16, 2011 - What is the value and impact of quality and safety teams?
A scoping review.
November 16, 2011
White DE, Straus SE, Stelfox T, et al. What is the value and impact of quality and safety teams? A scoping
review. Implement Sci. 2011;6:97. doi:10.1186/1748-5908-6-97.
https://psnet.ahrq.gov/issue/what-value-and-impact-q…
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psnet.ahrq.gov/node/38171/psn-pdf
June 29, 2009 - An educational and audit tool to reduce prescribing error
in intensive care.
June 29, 2009
Thomas AN, Boxall EM, Laha SK, et al. An educational and audit tool to reduce prescribing error in
intensive care. Qual Saf Health Care. 2008;17(5):360-3. doi:10.1136/qshc.2007.023242.
https://psnet.ahrq.gov/issue/educationa…
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psnet.ahrq.gov/node/38967/psn-pdf
June 09, 2011 - Eight rights of safe electronic health record use.
June 9, 2011
Sittig DF, Singh H. Eight rights of safe electronic health record use. JAMA. 2009;302(10):1111-3.
doi:10.1001/jama.2009.1311.
https://psnet.ahrq.gov/issue/eight-rights-safe-electronic-health-record-use
Incorporating human factors engineering models, t…
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psnet.ahrq.gov/node/35452/psn-pdf
January 05, 2017 - Deploying Six Sigma in a health care system as a work in
progress.
January 5, 2017
Christianson JB, Warrick LH, Howard R, et al. Deploying Six Sigma in a health care system as a work in
progress. Jt Comm J Qual Patient Saf. 2005;31(11):603-13.
https://psnet.ahrq.gov/issue/deploying-six-sigma-health-care-system-wor…
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psnet.ahrq.gov/training-catalog/capture-falls-collaboration-and-proactive-teamwork-used-reduce-falls-program
August 11, 2025 - CAPTURE Falls (Collaboration And Proactive Teamwork Used to Reduce Falls) Program
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Organization:
Organization
University of Nebraska College of…
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psnet.ahrq.gov/node/837808/psn-pdf
August 05, 2024 - Recognizing Excellence in Diagnosis: Recommended
Practices for Hospitals.
August 5, 2024
Washington, DC: Leapfrog Group; July 2024.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
Diagnostic safety is beginning to be established as a systemic, rather than solely an ind…
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psnet.ahrq.gov/node/38117/psn-pdf
September 29, 2017 - Advances in Patient Safety: New Directions and
Alternative Approaches.
September 29, 2017
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-
4).
https://psnet.ahrq.gov/issue/advances-patient-safety-new-directions-and-alternative-approaches
The 115 articles freel…
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psnet.ahrq.gov/node/38890/psn-pdf
December 30, 2014 - Intravenous infusion safety technology: return on
investment.
December 30, 2014
Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment.
Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680.
https://psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-invest…
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psnet.ahrq.gov/node/35980/psn-pdf
January 01, 2019 - The development of the National Reporting and Learning
System in England and Wales, 2001-2005.
December 23, 2012
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and
Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:10.5694/j.1326-5377.2006.tb00366.x.
ht…
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psnet.ahrq.gov/node/853629/psn-pdf
September 20, 2023 - Global Knowledge Sharing Platform for Patient Safety.
September 20, 2023
World Health Organization.
https://psnet.ahrq.gov/issue/global-knowledge-sharing-platform-patient-safety
The sharing of best practices is a key component of enabling successful strategy implementation in support
of patient safety plans and go…
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psnet.ahrq.gov/node/36754/psn-pdf
August 09, 2011 - Improving patient safety and communication through care
rounds in a pediatric oncology outpatient clinic.
August 9, 2011
Blough CA, Walrath JM. Improving patient safety and communication through care rounds in a pediatric
oncology outpatient clinic. J Nurs Care Qual. 2007;22(2):159-63.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/48052/psn-pdf
June 12, 2019 - How organisations contribute to improving the quality of
healthcare.
June 12, 2019
Fulop NJ, Ramsay AIG. How organisations contribute to improving the quality of healthcare. BMJ.
2019;365:l1773. doi:10.1136/bmj.l1773.
https://psnet.ahrq.gov/issue/how-organisations-contribute-improving-quality-healthcare
Quality a…
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psnet.ahrq.gov/node/73897/psn-pdf
September 29, 2021 - Peer Support Toolkit.
September 29, 2021
Betsy Lehman Center for Patient Safety. September 2021.
https://psnet.ahrq.gov/issue/peer-support-toolkit
Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This
toolkit is designed to assist organizations in the development o…
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psnet.ahrq.gov/node/37115/psn-pdf
October 04, 2011 - Evaluation of an anonymous system to report medical
errors in pediatric inpatients.
October 4, 2011
Taylor JA, Brownstein D, Klein EJ, et al. Evaluation of an anonymous system to report medical errors in
pediatric inpatients. J Hosp Med. 2007;2(4):226-33.
https://psnet.ahrq.gov/issue/evaluation-anonymous-system-re…
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psnet.ahrq.gov/node/45311/psn-pdf
May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd
Edition.
May 20, 2019
Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.
https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition
Checklists are a widely accepted strategy to improve communication and standardize processes to su…
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psnet.ahrq.gov/node/41713/psn-pdf
September 26, 2012 - Why patients need leaders: introducing a ward safety
checklist.
September 26, 2012
Amin Y, Grewcock D, Andrews S, et al. Why patients need leaders: introducing a ward safety checklist. J R
Soc Med. 2012;105(9):377-83. doi:10.1258/jrsm.2012.120098.
https://psnet.ahrq.gov/issue/why-patients-need-leaders-introducing-…
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psnet.ahrq.gov/node/41856/psn-pdf
November 21, 2012 - Electronic health records and National Patient-Safety
Goals.
November 21, 2012
Sittig DF, Singh H. Electronic Health Records and National Patient-Safety Goals. New England Journal of
Medicine. 2012;367(19). doi:10.1056/nejmsb1205420.
https://psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safet…
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psnet.ahrq.gov/node/50874/psn-pdf
February 05, 2020 - Checking In on the Checklist.
February 5, 2020
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
https://psnet.ahrq.gov/issue/checking-checklist
Checklists are integrated into error reduction strategies and healthcare team communication efforts
worldwide but implementation and impact of the tool varies …
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psnet.ahrq.gov/node/35311/psn-pdf
January 02, 2017 - Medication dosing errors for patients with renal
insufficiency in ambulatory care.
January 2, 2017
Yap C, Dunham D, Thompson JA, et al. Medication Dosing Errors for Patients with Renal Insufficiency in
Ambulatory Care. The Joint Commission Journal on Quality and Patient Safety. 2016;31(9).
doi:10.1016/s1553-7250(0…