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psnet.ahrq.gov/node/50673/psn-pdf
November 20, 2019 - The introduction of a Neurosurgical Postoperative
Checklist improved quality of care and patient safety.
November 20, 2019
Hall AJ, Toner NS, Bhatt PM. The introduction of a Neurosurgical Postoperative Checklist improved quality
of care and patient safety. Br J Neurosurg. 2019;33(5):495-499. doi:10.1080/02688697.20…
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psnet.ahrq.gov/node/50453/psn-pdf
October 09, 2019 - Effect of a sedation weaning protocol on safety and
medication use among hospitalized children post critical
illness
October 9, 2019
Solodiuk JC, Greco CD, O'Donnell KA, et al. Effect of a Sedation Weaning Protocol on Safety and
Medication Use among Hospitalized Children Post Critical Illness. J Pediatr Nurs. 2019…
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psnet.ahrq.gov/node/39003/psn-pdf
January 28, 2010 - Reducing in-hospital cardiac arrests and hospital
mortality by introducing a medical emergency team.
January 28, 2010
Konrad D, Jäderling G, Bell M, et al. Reducing in-hospital cardiac arrests and hospital mortality by
introducing a medical emergency team. Intensive Care Med. 2010;36(1):100-6. doi:10.1007/s00134-00…
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psnet.ahrq.gov/node/43937/psn-pdf
May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
May 5, 2018
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices
Benchmarks tracking a wide spectru…
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psnet.ahrq.gov/node/39879/psn-pdf
September 29, 2010 - The effect of resident duty hour restriction on trauma
center outcomes in teaching hospitals in the state of
Pennsylvania.
September 29, 2010
Helling TS, Kaswan S, Boccardo J, et al. The effect of resident duty hour restriction on trauma center
outcomes in teaching hospitals in the state of Pennsylvania. J Trauma.…
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psnet.ahrq.gov/node/42996/psn-pdf
March 19, 2014 - The "physician-led chart audit": engaging providers in
fortifying a culture of safety.
March 19, 2014
Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a
culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000000000000057.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/74065/psn-pdf
November 10, 2021 - AHRQ announces interest in research on digital
healthcare safety.
November 10, 2021
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021
Publication No. NOT-HS-22-004.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-digital-healthcare-safety
Digital in…
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psnet.ahrq.gov/node/46222/psn-pdf
June 21, 2017 - Enhanced time out: an improved communication process.
June 21, 2017
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570.
doi:10.1016/j.aorn.2017.03.014.
https://psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
The Universal Protocol requires hospitals t…
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psnet.ahrq.gov/node/43142/psn-pdf
June 15, 2014 - Development and sustainability of an inpatient-to-
outpatient discharge handoff tool: a quality improvement
project.
June 15, 2014
Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge
handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf. 2014;40(5…
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psnet.ahrq.gov/node/41466/psn-pdf
June 20, 2012 - Factors predicting change in hospital safety climate and
capability in a multi-site patient safety collaborative: a
longitudinal survey study.
June 20, 2012
Benn J, Burnett S, Parand A, et al. Factors predicting change in hospital safety climate and capability in a
multi-site patient safety collaborative: a longit…
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psnet.ahrq.gov/node/40784/psn-pdf
September 21, 2011 - Do remote community telepharmacies have higher
medication error rates than traditional community
pharmacies? Evidence from the North Dakota
Telepharmacy Project.
September 21, 2011
Friesner DL, Scott DM, Rathke AM, et al. Do remote community telepharmacies have higher medication
error rates than traditional commu…
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psnet.ahrq.gov/node/43159/psn-pdf
May 07, 2014 - Mandatory presuit mediation: 5-year results of a medical
malpractice resolution program.
May 7, 2014
Jenkins RC, Smillov AE, Goodwin MA. Mandatory presuit mediation: 5-year results of a medical
malpractice resolution program. J Healthc Risk Manag. 2014;33(4):15-22. doi:10.1002/jhrm.21138.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42048/psn-pdf
July 01, 2013 - Striving for a zero-error patient surgical journey through
adoption of aviation-style challenge and response flow
checklists: a quality improvement project.
July 1, 2013
Low DK, Reed MA, Geiduschek JM, et al. Striving for a zero-error patient surgical journey through adoption
of aviation-style challenge and respon…
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psnet.ahrq.gov/node/47355/psn-pdf
September 05, 2018 - Preventing medication errors in the information age.
September 5, 2018
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-
58. doi:10.1097/01.NURSE.0000544230.51598.38.
https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age
Failure to consider…
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psnet.ahrq.gov/node/47913/psn-pdf
April 10, 2019 - Improving standardization of paging communication
using quality improvement methodology.
April 10, 2019
Weigert RM, Schmitz AH, Soung PJ, et al. Improving Standardization of Paging Communication Using
Quality Improvement Methodology. Pediatrics. 2019;143(4). doi:10.1542/peds.2018-1362.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/36558/psn-pdf
May 27, 2011 - The National Quality Forum safe practice standard for
computerized physician order entry: updating a critical
patient safety practice.
May 27, 2011
Kilbridge PM, Classen D, Bates DW, et al. The National Quality Forum Safe Practice Standard for
Computerized Physician Order Entry. J Patient Saf. 2008;2(4). doi:10.10…
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psnet.ahrq.gov/node/47087/psn-pdf
May 02, 2018 - The Economics of Patient Safety in Primary and
Ambulatory Care: Flying Blind.
May 2, 2018
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and
Development; 2018.
https://psnet.ahrq.gov/issue/economics-patient-safety-primary-and-ambulatory-care-flying-blind
The global eco…
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psnet.ahrq.gov/node/47107/psn-pdf
June 20, 2018 - Challenges in communication from referring clinicians to
pathologists in the electronic health record era.
June 20, 2018
Barbieri AL, Fadare O, Fan L, et al. Challenges in Communication from Referring Clinicians to Pathologists
in the Electronic Health Record Era. J Pathol Inform. 2018;9:8. doi:10.4103/jpi.jpi_70_1…
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psnet.ahrq.gov/node/43736/psn-pdf
April 24, 2017 - Seeing risk and allocating responsibility: talk of culture
and its consequences on the work of patient safety.
April 24, 2017
Szymczak JE. Seeing risk and allocating responsibility: talk of culture and its consequences on the work of
patient safety. Soc Sci Med. 2014;120:252-9. doi:10.1016/j.socscimed.2014.09.023.
…
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psnet.ahrq.gov/node/47057/psn-pdf
July 14, 2018 - A framework for operationalizing risk: a practical
approach to patient safety.
July 14, 2018
Mathews SC, Sutcliffe K, Garrett MR, et al. A framework for operationalizing risk: A practical approach to
patient safety. J Healthc Risk Manag. 2018;38(1):38-46. doi:10.1002/jhrm.21317.
https://psnet.ahrq.gov/issue/frame…