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psnet.ahrq.gov/node/43636/psn-pdf
November 26, 2014 - Application of the WHO surgical safety checklist outside
the operating theatre: medicine can learn from surgery.
November 26, 2014
Braham DL, Richardson AL, Malik IS. Application of the WHO surgical safety checklist outside the
operating theatre: medicine can learn from surgery. Clin Med. 2014;14(5):468-474.
doi:1…
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psnet.ahrq.gov/node/46057/psn-pdf
September 24, 2017 - Narrative feedback from OR personnel about the safety of
their surgical practice before and after a surgical safety
checklist intervention.
September 24, 2017
Alidina S, Hur H-C, Berry WR, et al. Narrative feedback from OR personnel about the safety of their
surgical practice before and after a surgical safety che…
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psnet.ahrq.gov/node/73112/psn-pdf
April 07, 2021 - Smartphone distraction during nursing care: systematic
literature review.
April 7, 2021
Fiorinelli M, Di Mario S, Surace A, et al. Smartphone distraction during nursing care: systematic literature
review. Appl Nurs Res. 2021;58:151405. doi:10.1016/j.apnr.2021.151405.
https://psnet.ahrq.gov/issue/smartphone-distrac…
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psnet.ahrq.gov/node/73575/psn-pdf
August 04, 2021 - Unlocking Solutions in Imaging: Working Together to
Learn from Failings in the NHS.
August 4, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.
https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
Lack of appropriate follow up o…
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psnet.ahrq.gov/node/39707/psn-pdf
January 07, 2015 - Introduction of a rapid response system at a United
States Veterans Affairs hospital reduced cardiac arrests.
January 7, 2015
Lighthall GK, Parast L, Rapoport L, et al. Introduction of a rapid response system at a United States
veterans affairs hospital reduced cardiac arrests. Anesth Analg. 2010;111(3):679-86.
do…
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psnet.ahrq.gov/node/46922/psn-pdf
January 01, 2019 - Reducing interdisciplinary communication failures
through secure text messaging: a quality improvement
project.
March 21, 2018
Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure
Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/pq9.0000000000000053.
https://ps…
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psnet.ahrq.gov/node/42002/psn-pdf
May 10, 2013 - National efforts to improve health information system
safety in Canada, the United States of America and
England.
May 10, 2013
Kushniruk AW, Bates DW, Bainbridge M, et al. National efforts to improve health information system safety
in Canada, the United States of America and England. Int J Med Inform. 2013;82(5):…
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psnet.ahrq.gov/node/44320/psn-pdf
October 28, 2015 - Interventions for reducing medication errors in children in
hospital.
October 28, 2015
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in
hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3.
https://psnet.ahrq.gov/issue/int…
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psnet.ahrq.gov/node/73589/psn-pdf
August 11, 2021 - Suicide and suicide attempts on hospital grounds and
clinic areas.
August 11, 2021
Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J
Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356.
https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
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psnet.ahrq.gov/node/39773/psn-pdf
August 18, 2010 - Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider
order entry warning system.
August 18, 2010
Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider order e…
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psnet.ahrq.gov/node/45298/psn-pdf
April 22, 2017 - The problem with root cause analysis.
April 22, 2017
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-
422. doi:10.1136/bmjqs-2016-005511.
https://psnet.ahrq.gov/issue/problem-root-cause-analysis
Root cause analysis (RCA) is a strategy to investigate incident…
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psnet.ahrq.gov/node/72708/psn-pdf
February 03, 2021 - How communication "failed" or "saved the day":
counterfactual accounts of medical errors.
February 3, 2021
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual
Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1177/2374373520925270.
https://p…
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psnet.ahrq.gov/node/36734/psn-pdf
March 10, 2011 - Integrating incident reporting into an electronic patient
record system.
March 10, 2011
Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record
system. J Am Med Inform Assoc. 2007;14(2):175-81.
https://psnet.ahrq.gov/issue/integrating-incident-reporting-electronic…
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psnet.ahrq.gov/node/43469/psn-pdf
August 27, 2014 - Effect of using a safety checklist on patient complications
after surgery: a systematic review and meta-analysis.
August 27, 2014
Gillespie BM, Chaboyer W, Thalib L, et al. Effect of using a safety checklist on patient complications after
surgery: a systematic review and meta-analysis. Anesthesiology. 2014;120(6):1…
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psnet.ahrq.gov/node/38174/psn-pdf
November 05, 2008 - National Surgical Quality Improvement Program.
November 5, 2008
American College of Surgeons.
https://psnet.ahrq.gov/issue/national-surgical-quality-improvement-program
During the 1980s, the Department of Veterans Affairs (VA) received significant public scrutiny over the
quality of surgical care in their hospital…
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psnet.ahrq.gov/node/39859/psn-pdf
November 21, 2016 - Experience with family activation of rapid response
teams.
November 21, 2016
Bogert S, Ferrell C, Rutledge DN. Experience with family activation of rapid response teams. Medsurg
Nurs. 2010;19(4):215-22; quiz 223.
https://psnet.ahrq.gov/issue/experience-family-activation-rapid-response-teams
The central tenet behi…
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psnet.ahrq.gov/node/850353/psn-pdf
June 14, 2023 - Perioperative handoff enhancement opportunities
through technology and artificial intelligence: a narrative
review.
June 14, 2023
Sparling J, Hong Mershon B, Abraham J. Perioperative handoff enhancement opportunities through
technology and artificial intelligence: a narrative review. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/74871/psn-pdf
October 01, 2023 - AHRQ Safety Program for MRSA Prevention.
February 14, 2023
Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.
https://psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention
Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. Thi…
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psnet.ahrq.gov/node/867643/psn-pdf
February 26, 2025 - Psychology insights on apologizing to patients.
February 26, 2025
Redelmeier DA, Roach J. Psychology insights on apologizing to patients. J Hosp Med. 2024;Epub Dec 30.
doi:10.1002/jhm.13585.
https://psnet.ahrq.gov/issue/psychology-insights-apologizing-patients
Apologizing to the patient and family after a harmful …
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psnet.ahrq.gov/node/40736/psn-pdf
January 04, 2012 - Preventing wrong site, procedure, and patient events
using a common cause analysis.
January 4, 2012
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a
common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/1062860611412066.
https://psnet.ahrq.gov/issue/p…