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psnet.ahrq.gov/node/38737/psn-pdf
July 13, 2009 - Reengineering hospital discharge: a protocol to improve
patient safety, reduce costs, and boost patient
satisfaction.
July 13, 2009
Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and
boost patient satisfaction. Am J Med Qual. 2009;24(4):344-6. doi:10.1177/106286060…
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psnet.ahrq.gov/node/857446/psn-pdf
December 06, 2023 - Community Health Systems’ ongoing journey to zero
preventable harm.
December 6, 2023
Simon LT, Van Buren T. Community Health Systems’ ongoing journey to zero preventable harm. NEJM
Catal Innov Care Deliv. 2023;4(12). doi:10.1056/cat.23.0250.
https://psnet.ahrq.gov/issue/community-health-systems-ongoing-journey-zer…
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psnet.ahrq.gov/node/854834/psn-pdf
January 01, 2024 - Bringing the equity lens to patient safety event reporting.
October 25, 2023
Gandhi TK, Schulson LB, Thomas AD. Bringing the equity lens to patient safety event reporting. Jt Comm J
Qual Patient Saf. 2024;50(1):87-89. doi:10.1016/j.jcjq.2023.09.003.
https://psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-e…
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psnet.ahrq.gov/node/44871/psn-pdf
April 22, 2016 - Making checklists work: South Carolina's statewide
experiment.
April 22, 2016
Rice S. MAKING CHECKLISTS WORK. Modern healthcare. 2016;46(4):14-6.
https://psnet.ahrq.gov/issue/making-checklists-work-south-carolinas-statewide-experiment
Although checklist implementation as a safety strategy has achieved some success…
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psnet.ahrq.gov/node/47827/psn-pdf
February 27, 2019 - Improving Usability, Safety and Patient Outcomes With
Health Information Technology.
February 27, 2019
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN:
9781614999508.
https://psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technol…
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34646/psn-pdf
July 01, 2015 - The attributes of medical event reporting systems.
July 1, 2015
Battles JB, Kaplan HS, van der Schaaf TW, et al. The attributes of medical event-reporting systems:
experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med.
1998;122(3):231-8.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/839814/psn-pdf
January 01, 2023 - Influencing a culture of quality and safety through
huddles.
November 9, 2022
McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles.
J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642.
https://psnet.ahrq.gov/issue/influencing-culture-quality-a…
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psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - Nowhere is safe: record number of patients contracted
Covid in the hospital in January.
March 2, 2022
Levy R, Vestal AJ. Politico. February 19, 2022.
https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
Transmission of COVID-19 in the health care setting continues to b…
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psnet.ahrq.gov/node/837077/psn-pdf
May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes
away.
May 11, 2022
Kelman B. Kaiser Health News. April 29, 2022.
https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away
Technological solutions harbor unique risks that can result in patient harm. This article shares a response
to report…
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psnet.ahrq.gov/node/846762/psn-pdf
March 29, 2023 - Hospital ‘black boxes’ put surgical practices under the
microscope.
March 29, 2023
Sadick B. Wall Street Journal. March 19, 2023.
https://psnet.ahrq.gov/issue/hospital-black-boxes-put-surgical-practices-under-microscope
Safety information systems that track action in real time can reveal a trove of data about how …
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psnet.ahrq.gov/node/46005/psn-pdf
July 11, 2018 - The 2016 John M. Eisenberg Patient Safety and Quality
Awards.
July 11, 2018
Jt Comm J Qual Patient Saf. 2017;43:315-337.
https://psnet.ahrq.gov/issue/2016-john-m-eisenberg-patient-safety-and-quality-awards
Spotlighting the accomplishments of the 2016 recipients of the John M. Eisenberg Patient Safety and
Quality …
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psnet.ahrq.gov/node/42971/psn-pdf
February 26, 2014 - Reducing central line–associated bloodstream infections
in North Carolina NICUs.
February 26, 2014
Fisher D, Cochran KM, Provost LP, et al. Reducing central line-associated bloodstream infections in North
Carolina NICUs. Pediatrics. 2013;132(6):e1664-71. doi:10.1542/peds.2013-2000.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/39695/psn-pdf
July 21, 2010 - The impact of the 80-hour work week on appropriate
resident case coverage.
July 21, 2010
Shin S, Britt R, Doviak M, et al. The Impact of the 80-Hour Work Week on Appropriate Resident Case
Coverage. Journal of Surgical Research. 2009;162(1). doi:10.1016/j.jss.2009.12.003.
https://psnet.ahrq.gov/issue/impact-80-hour…
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psnet.ahrq.gov/node/45257/psn-pdf
July 27, 2016 - Exploring approaches to patient safety: the case of spinal
manipulation therapy.
July 27, 2016
Rozmovits L, Mior S, Boon H. Exploring approaches to patient safety: the case of spinal manipulation
therapy. BMC Complement Altern Med. 2016;16:164. doi:10.1186/s12906-016-1149-2.
https://psnet.ahrq.gov/issue/exploring-…
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psnet.ahrq.gov/node/39789/psn-pdf
August 25, 2010 - Using evidence, rigorous measurement, and collaboration
to eliminate central catheter-associated bloodstream
infections.
August 25, 2010
Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to
eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…
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psnet.ahrq.gov/node/38555/psn-pdf
April 15, 2009 - Standardized sign-out reduces intern perception of
medical errors on the general internal medicine ward.
April 15, 2009
Salerno SM, Arnett M, Domanski JP. Standardized sign-out reduces intern perception of medical errors on
the general internal medicine ward. Teach Learn Med. 2009;21(2):121-6.
doi:10.1080/10401330…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/36224/psn-pdf
October 19, 2010 - Nonpunitive medication error reporting: 3-year findings
from one hospital's primum non nocere initiative.
October 19, 2010
Potylycki MJ, Kimmel SR, Ritter M, et al. Nonpunitive medication error reporting: 3-year findings from one
hospital's Primum Non Nocere initiative. J Nurs Adm. 2006;36(7-8):370-376.
https://ps…
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psnet.ahrq.gov/node/41559/psn-pdf
August 01, 2012 - Design and trial of a new ambulance-to-emergency
department handover protocol: 'IMIST-AMBO.'
August 1, 2012
Iedema R, Ball C, Daly B, et al. Design and trial of a new ambulance-to-emergency department handover
protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012;21(8):627-33. doi:10.1136/bmjqs-2011-000766.
https://psnet.ahr…