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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - Governing the safety of artificial intelligence in
healthcare.
May 20, 2019
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498.
doi:10.1136/bmjqs-2019-009484.
https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risk…
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psnet.ahrq.gov/node/865931/psn-pdf
July 22, 2024 - Examining the Impact of Artificial Intelligence (AI) on
Healthcare Safety (R18).
July 22, 2024
Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261.
https://psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcement-examining-impact-
artificial
Health systems are increasingly …
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psnet.ahrq.gov/node/60990/psn-pdf
October 07, 2020 - Tiered daily huddles: the power of teamwork in managing
large healthcare organisations.
October 7, 2020
Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ
Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575.
https://psnet.ahrq.gov/issue/tiered-daily…
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psnet.ahrq.gov/node/43232/psn-pdf
June 04, 2014 - Standardization in patient safety: the WHO High 5s
project.
June 4, 2014
Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO High 5s project. Int J
Qual Health Care. 2014;26(2):109-16. doi:10.1093/intqhc/mzu010.
https://psnet.ahrq.gov/issue/standardization-patient-safety-who-high-5s-…
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - PowerPoint Presentation
Spotlight
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
1
This presentation is based on the June 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - We spoke
with them about their experience implementing remote patient monitoring (RPM) programs, GW’
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psnet.ahrq.gov/node/73365/psn-pdf
June 09, 2021 - Enhancing psychological safety in mental health services.
June 9, 2021
Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment
Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1.
https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…
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psnet.ahrq.gov/node/37134/psn-pdf
March 23, 2011 - Effect of crew resource management on diabetes care
and patient outcomes in an inner-city primary care clinic.
March 23, 2011
Taylor CR, Hepworth JT, Buerhaus P, et al. Effect of crew resource management on diabetes care and
patient outcomes in an inner-city primary care clinic. Qual Saf Health Care. 2007;16(4):244…
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psnet.ahrq.gov/node/45469/psn-pdf
January 18, 2017 - Tamper-resistant drugs cannot solve the opioid crisis.
January 18, 2017
Leece P, Orkin AM, Kahan M. Tamper-resistant drugs cannot solve the opioid crisis. CMAJ.
2015;187(10):717-718. doi:10.1503/cmaj.150329.
https://psnet.ahrq.gov/issue/tamper-resistant-drugs-cannot-solve-opioid-crisis
Health care organizations ha…
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psnet.ahrq.gov/node/45846/psn-pdf
January 07, 2019 - Medication safety in the operating room: literature and
expert-based recommendations.
January 7, 2019
Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert-
based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew379.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47630/psn-pdf
February 27, 2019 - Teaching about diagnostic errors through virtual patient
cases: a pilot exploration.
February 27, 2019
Geha R, Trowbridge RL, Dhaliwal G, et al. Teaching about diagnostic errors through virtual patient cases: a
pilot exploration. Diagnosis (Berl). 2018;5(4):223-227. doi:10.1515/dx-2018-0023.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837154/psn-pdf
May 18, 2022 - Survey shows room for improvement with three new best
practices for hospitals.
May 18, 2022
ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.
https://psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals
Practice changes take time to be fully incorporate…
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psnet.ahrq.gov/node/42117/psn-pdf
March 20, 2013 - Nurse–patient ratios as a patient safety strategy: a
systematic review.
March 20, 2013
Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med.
2013;158(5 Pt 2):404-409. doi:10.7326/0003-4819-158-5-201303051-00007.
https://psnet.ahrq.gov/issue/nurse-patient-ratios-patien…
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psnet.ahrq.gov/node/45752/psn-pdf
January 11, 2017 - TeamSTEPPS in long-term care- an academic partnership:
part 1 and part 2.
January 11, 2017
Roman TC, Abraham K, Dever K. TeamSTEPPS in Long-Term Care-An Academic Partnership: Part I. J
Contin Educ Nurs. 2016;47(11):490-492. doi:10.3928/00220124-20161017-06.
https://psnet.ahrq.gov/issue/teamstepps-long-term-care-ac…
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psnet.ahrq.gov/node/60983/psn-pdf
October 07, 2020 - A qualitative exploration of the impact of a distressed
family member on pediatric resuscitation teams.
October 7, 2020
Deacon A, O’Neill T, Delaloye N, et al. A qualitative exploration of the impact of a distressed family member
on pediatric resuscitation teams. Hosp Pediatr. 2020;10(9):758-766. doi:10.1542/hpeds.…
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psnet.ahrq.gov/node/39356/psn-pdf
April 08, 2011 - Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations.
April 8, 2011
Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…
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psnet.ahrq.gov/node/47872/psn-pdf
March 27, 2019 - Overview of the Environmental Scan of Primary Care-
Based Effort To Reduce Readmissions.
March 27, 2019
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality;
March 2019. AHRQ Publication No. 18(19)-0055-EF.
https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…
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psnet.ahrq.gov/node/866256/psn-pdf
July 10, 2024 - Disclosure programmes in the US--an inadequate
response to medical error.
July 10, 2024
Handley GM. Disclosure programmes in the US—an inadequate response to medical error. BMJ.
2024;385:q1318. doi:10.1136/bmj.q1318.
https://psnet.ahrq.gov/issue/disclosure-programmes-us-inadequate-response-medical-error
Communica…
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psnet.ahrq.gov/node/46287/psn-pdf
April 12, 2019 - Anesthesia adverse events voluntarily reported in the
Veterans Health Administration and lessons learned.
April 12, 2019
Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesthesia Adverse Events Voluntarily Reported in the Veterans
Health Administration and Lessons Learned. Anesth Analg. 2017;126(2):471-477.
doi:10.12…