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psnet.ahrq.gov/node/38564/psn-pdf
April 15, 2009 - The effects of aviation-style non-technical skills training
on technical performance and outcome in the operating
theatre.
April 15, 2009
McCulloch P, Mishra A, Handa A, et al. The effects of aviation-style non-technical skills training on
technical performance and outcome in the operating theatre. Qual Saf Healt…
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psnet.ahrq.gov/node/867144/psn-pdf
November 13, 2024 - Life of the Mother. How Abortion Bans Lead to
Preventable Deaths.
November 13, 2024
Jaramillo C, Surana K, Presser L, et al. Life of the Mother. How Abortion Bans Lead to Preventable Deaths.
ProPublica. 2024:September - November 2024.
https://psnet.ahrq.gov/issue/life-mother-how-abortion-bans-lead-preventable-deat…
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psnet.ahrq.gov/node/42579/psn-pdf
November 18, 2013 - Surgical safety checklist compliance: a job done poorly!
November 18, 2013
Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J
Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393.
https://psnet.ahrq.gov/issue/surgical-safety-checklist-com…
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psnet.ahrq.gov/node/38274/psn-pdf
March 31, 2009 - Time motion study in a pediatric emergency department
before and after computer physician order entry.
March 31, 2009
Yen K, Shane EL, Pawar SS, et al. Time motion study in a pediatric emergency department before and
after computer physician order entry. Ann Emerg Med. 2009;53(4):462-468.e1.
doi:10.1016/j.annemerg…
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psnet.ahrq.gov/node/42997/psn-pdf
May 28, 2014 - Exploring perinatal shift-to-shift handover communication
and process: an observational study.
May 28, 2014
Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and
process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103.
https:/…
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psnet.ahrq.gov/node/60878/psn-pdf
January 01, 2021 - Intervention study for the reduction of medication errors
in elderly trauma patients.
September 2, 2020
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. Intervention study for the reduction of
medication errors in elderly trauma patients. J Eval Clin Pract. 2021;27(1):160-166. doi:10.1111/jep.134…
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psnet.ahrq.gov/node/60768/psn-pdf
August 05, 2020 - Missed and delayed diagnoses of non-COVID conditions--
collateral harm from a pandemic.
August 5, 2020
Carr S. Missed and delayed diagnoses of non-COVID conditions- collateral harm from a pandemic.
ImproveDx. 2020;7(4):1-5.
https://psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-non-covid-conditions-collateral-h…
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psnet.ahrq.gov/node/43465/psn-pdf
February 18, 2015 - Hospital Readmissions Reduction Program: implications
for pharmacy.
February 18, 2015
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for
pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
https://psnet.ahrq.gov/issue/hospital-readmissions-redu…
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psnet.ahrq.gov/node/42931/psn-pdf
April 20, 2014 - Assigning a team-based pager for on-call physicians
reduces paging errors in a large academic hospital.
April 20, 2014
Shieh L, Chi J, Kulik C, et al. Assigning a team-based pager for on-call physicians reduces paging errors in
a large academic hospital. Jt Comm J Qual Patient Saf. 2014;40(2):77-82.
https://psnet.…
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psnet.ahrq.gov/node/46374/psn-pdf
August 30, 2017 - Structured patient handoffs: the movement toward
adverse event reduction in the perioperative unit.
August 30, 2017
Hamilton WL.
https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction-
perioperative-unit
Miscommunication during care transitions can contribute to medical e…
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psnet.ahrq.gov/node/850911/psn-pdf
June 21, 2023 - International perspectives on modifications to the
surgical safety checklist.
June 21, 2023
Turley N, Elam M, Brindle ME. International perspectives on modifications to the surgical safety checklist.
JAMA Netw Open. 2023;6(6):e2317183. doi:10.1001/jamanetworkopen.2023.17183.
https://psnet.ahrq.gov/issue/internatio…
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psnet.ahrq.gov/node/60914/psn-pdf
September 16, 2020 - Opioid stewardship program and postoperative adverse
events: a difference-in-differences cohort study.
September 16, 2020
Barreveld AM, McCarthy RJ, Elkassabany N, et al. Opioid stewardship program and postoperative adverse
events: a difference-in-differences cohort study. Anesthesiology. 2020;132(6):1558-1568.
do…
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psnet.ahrq.gov/node/47074/psn-pdf
August 22, 2018 - Influences on the adoption of patient safety innovation in
primary care: a qualitative exploration of staff
perspectives.
August 22, 2018
Litchfield I, Gill P, Avery T, et al. Influences on the adoption of patient safety innovation in primary care: a
qualitative exploration of staff perspectives. BMC Fam Pract. 20…
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psnet.ahrq.gov/node/41080/psn-pdf
May 29, 2012 - Development and evaluation of a checklist to support
decision making in cancer multidisciplinary team
meetings: MDT-QuIC.
May 29, 2012
Lamb BW, Sevdalis N, Vincent C, et al. Development and evaluation of a checklist to support decision
making in cancer multidisciplinary team meetings: MDT-QuIC. Ann Surg Oncol. 201…
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psnet.ahrq.gov/node/47601/psn-pdf
December 21, 2018 - Clinical decision support in the era of artificial
intelligence.
December 21, 2018
Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA.
2018;320(21):2199-2200. doi:10.1001/jama.2018.17163.
https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/46866/psn-pdf
May 23, 2018 - Improving maternal safety at scale with the mentor model
of collaborative improvement.
May 23, 2018
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of
Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259.
doi:10.1016/j.jcjq.2017.11.005.
https://psn…
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psnet.ahrq.gov/node/46901/psn-pdf
May 30, 2018 - Physician resiliency and wellness for transforming a
health system.
May 30, 2018
Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018.
https://psnet.ahrq.gov/issue/physician-resiliency-and-wellness-transforming-health-system
Physician burnout can contribute to medical errors. This article discusses an organizational e…