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psnet.ahrq.gov/node/854255/psn-pdf
October 04, 2023 - Empowering telemetry technicians and enhancing
communication to improve in-hospital cardiac arrest
survival.
October 4, 2023
McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to
improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
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psnet.ahrq.gov/node/47020/psn-pdf
January 16, 2019 - Unintended harm associated with the Hospital
Readmissions Reduction Program.
January 16, 2019
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA.
2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
https://psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmiss…
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psnet.ahrq.gov/node/73472/psn-pdf
July 07, 2021 - Safety checklists for emergency response driving and
patient transport: experiences from emergency medical
services.
July 7, 2021
Jakonen A, Mänty M, Nordquist H. Safety checklists for emergency response driving and patient transport:
experiences from emergency medical services. Jt Comm J Qual Patient Saf. 2021;47…
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psnet.ahrq.gov/node/44267/psn-pdf
October 13, 2015 - Crew resource management in the intensive care unit: a
prospective 3-year cohort study.
October 13, 2015
Haerkens MHTM, Kox M, Lemson J, et al. Crew Resource Management in the Intensive Care Unit: a
prospective 3-year cohort study. Acta Anaesthesiol Scand. 2015;59(10):1319-29. doi:10.1111/aas.12573.
https://psnet.…
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psnet.ahrq.gov/node/47227/psn-pdf
October 03, 2018 - Clinical and financial effects of smart pump-electronic
medical record interoperability at a hospital in a regional
health system.
October 3, 2018
Biltoft J, Finneman L. Clinical and financial effects of smart pump-electronic medical record interoperability
at a hospital in a regional health system. Am J Health Sy…
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psnet.ahrq.gov/node/46426/psn-pdf
September 28, 2017 - Toward more proactive approaches to safety in the
electronic health record era.
September 28, 2017
Sittig DF, Singh H. Toward More Proactive Approaches to Safety in the Electronic Health Record Era. Jt
Comm J Qual Patient Saf. 2017;43(10):540-547. doi:10.1016/j.jcjq.2017.06.005.
https://psnet.ahrq.gov/issue/toward…
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psnet.ahrq.gov/node/45868/psn-pdf
January 31, 2018 - Increasing trainee reporting of adverse events with
monthly, trainee-directed review of adverse events.
January 31, 2018
Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee-
Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906. doi:10.1016/j.acap.2017.01.00…
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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/43162/psn-pdf
June 16, 2014 - The use of report cards and outcome measurements to
improve the safety of surgical care: the American College
of Surgeons National Surgical Quality Improvement
Program.
June 16, 2014
Maggard-Gibbons M. The use of report cards and outcome measurements to improve the safety of surgical
care: the American College of…
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psnet.ahrq.gov/node/40617/psn-pdf
November 01, 2011 - Increasing medication error reporting rates while
reducing harm through simultaneous cultural and
system-level interventions in an intensive care unit.
November 1, 2011
Abstoss KM, Shaw BE, Owens TA, et al. Increasing medication error reporting rates while reducing harm
through simultaneous cultural and system-lev…
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psnet.ahrq.gov/node/50823/psn-pdf
January 22, 2020 - Reducing inappropriate polypharmacy in primary care
through pharmacy-led interventions.
January 22, 2020
Bryant E, Claire K, Needham R. Reducing inappropriate polypharmacy in primary care through pharmacy-
led interventions. Pharm J. 2019;303(7932). doi:10.1211/pj.2019.20207385.
https://psnet.ahrq.gov/issue/reduci…
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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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psnet.ahrq.gov/node/44748/psn-pdf
August 19, 2016 - Beyond clinical engagement: a pragmatic model for
quality improvement interventions, aligning clinical and
managerial priorities.
August 19, 2016
Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality
improvement interventions, aligning clinical and managerial priorities. BM…
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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…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…
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psnet.ahrq.gov/node/864371/psn-pdf
March 13, 2024 - The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals.
March 13, 2024
Facey M, Baxter NN, Hammond Mobilio M, et al. The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals. Sociol Health Illn. 2024;46(6):1100-1118. doi:10.1111/1467-
…
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psnet.ahrq.gov/node/43860/psn-pdf
March 25, 2015 - Pharmacy dispensing errors: claims study emphasizes
need for systematic vigilance.
March 25, 2015
Webb J. Drug Topics. March 10, 2015.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-
vigilance
Pharmacies can serve as gatekeepers to ensure patients receive the corre…
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psnet.ahrq.gov/node/72600/psn-pdf
December 23, 2020 - Improving hospital safety culture for falls prevention
through interdisciplinary health education.
December 23, 2020
Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary
health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337.
htt…
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psnet.ahrq.gov/node/47400/psn-pdf
November 28, 2018 - Impact of the communication and patient hand-off tool
SBAR on patient safety: a systematic review.
November 28, 2018
Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on
patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202…
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psnet.ahrq.gov/node/849136/psn-pdf
May 17, 2023 - Using morbidity and mortality conferences to drive
quality improvement and reduce errors.
May 17, 2023
Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-
reduce-errors
Morbidity and mortality (…