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psnet.ahrq.gov/node/48073/psn-pdf
June 19, 2019 - Special Section on Human Factors and Ergonomics in the
Operating Room: Contributions That Advance Surgical
Practice.
June 19, 2019
Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.
https://psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-
advance-surgical
Surg…
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psnet.ahrq.gov/node/46528/psn-pdf
January 10, 2018 - Five Years of Experience Using Front-line Ownership to
Improve Healthcare Quality and Safety.
January 10, 2018
Healthc Pap. 2017;17:1-61.
https://psnet.ahrq.gov/issue/five-years-experience-using-front-line-ownership-improve-healthcare-quality-
and-safety
Patient safety leaders have noted the need to recognize the…
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psnet.ahrq.gov/node/43805/psn-pdf
February 11, 2015 - Understanding the nature of medication errors in an ICU
with a computerized physician order entry system.
February 11, 2015
Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a
computerized physician order entry system. PLoS One. 2014;9(12):e114243.
doi:10.1371/journal.pon…
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - FDA Safety Communication: use caution with implanted
pumps for intrathecal administration of medicines for
pain management.
November 28, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
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psnet.ahrq.gov/node/851917/psn-pdf
January 01, 2024 - Incivility in healthcare: the impact of poor
communication.
August 2, 2023
Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead.
2024;8(1):83-87. doi:10.1136/leader-2022-000717.
https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication
Incivi…
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psnet.ahrq.gov/node/39264/psn-pdf
February 03, 2010 - Changing cardiac arrest and hospital mortality rates
through a medical emergency team takes time and
constant review.
February 3, 2010
Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical
emergency team takes time and constant review. Crit Care Med. 2010;38(2):445…
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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - Verifying patient identity and site of surgery: improving
compliance with protocol by audit and feedback.
January 14, 2009
Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance
with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8.
doi:10.11…
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psnet.ahrq.gov/node/41515/psn-pdf
July 02, 2014 - Anticipated consequences of the 2011 duty hours
standards: views of internal medicine and surgery
program directors.
July 2, 2014
Shea JA, Willett LL, Borman KR, et al. Anticipated consequences of the 2011 duty hours standards: views
of internal medicine and surgery program directors. Acad Med. 2012;87(7):895-903.…
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psnet.ahrq.gov/node/44952/psn-pdf
March 02, 2016 - Engaging pediatric resident physicians in quality
improvement through resident-led morbidity and mortality
conferences.
March 2, 2016
Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through
Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/48034/psn-pdf
May 22, 2019 - Chasing zero harm in radiation oncology: using pre-
treatment peer review.
May 22, 2019
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-
treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
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psnet.ahrq.gov/node/60974/psn-pdf
September 30, 2020 - Covid-19: Assessing the Risk to Public Protection Posed
by a Doctor as a Result of Concerns about their Practice
during the Pandemic.
September 30, 2020
London, UK: General Medical Council; September 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-assessing-risk-public-protection-posed-doctor-result-concerns-about…
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psnet.ahrq.gov/node/39088/psn-pdf
September 01, 2015 - Laboratory session to improve first-year pharmacy
students' knowledge and confidence concerning the
prevention of medication errors.
September 1, 2015
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students'
knowledge and confidence concerning the prevention of medica…
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psnet.ahrq.gov/node/43516/psn-pdf
June 15, 2017 - Application of failure mode effect analysis to improve the
care of septic patients admitted through the emergency
department.
June 15, 2017
Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of
Septic Patients Admitted Through the Emergency Department. J Patient …
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psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
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psnet.ahrq.gov/node/45138/psn-pdf
May 25, 2016 - Improving Weekend Out Of Hours Surgical Handover
(WOOSH).
May 25, 2016
Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ
Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190.
https://psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh
…
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psnet.ahrq.gov/node/48018/psn-pdf
July 31, 2019 - PEARLS for systems integration: a modified PEARLS
framework for debriefing systems-focused simulations.
July 31, 2019
Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for
Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342.
doi:10.1097/SIH.0000000000…
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psnet.ahrq.gov/node/37193/psn-pdf
October 06, 2011 - Incomplete EHR adoption: late uptake of patient safety
and cost control functions.
October 6, 2011
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost
control functions. Am J Med Qual. 2007;22(5):319-26.
https://psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-u…
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psnet.ahrq.gov/node/43182/psn-pdf
May 14, 2014 - Quality and safety in pediatric anesthesia: how can
guidelines, checklists, and initiatives improve the
outcome?
May 14, 2014
Hagerman NS, Varughese AM, Kurth D. Quality and safety in pediatric anesthesia: how can guidelines,
checklists, and initiatives improve the outcome? Curr Opin Anaesthesiol. 2014;27(3):323-9…
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psnet.ahrq.gov/node/866642/psn-pdf
September 04, 2024 - Learning from patient safety incidents: The Green Cross
method.
September 4, 2024
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method.
Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cro…