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psnet.ahrq.gov/node/73480/psn-pdf
December 17, 2024 - Improving Patient Safety with Human Factors Methods.
December 17, 2024
Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025.
https://psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
Human factors engineering (HFE) is a primary strategy for advancing safety in healt…
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psnet.ahrq.gov/node/36072/psn-pdf
July 05, 2006 - VA Health Care: Steps Taken to Improve Practitioner
Screening, but Facility Compliance with Screening
Requirements is Poor.
July 5, 2006
Washington DC; Government Accountability Office; May 2006. Report no GAO-06-544.
https://psnet.ahrq.gov/issue/va-health-care-steps-taken-improve-practitioner-screening-facility-c…
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psnet.ahrq.gov/node/38137/psn-pdf
October 15, 2008 - Ethical and legal issues in the use of health information
technology to improve patient safety.
October 15, 2008
Berner ES. Ethical and legal issues in the use of health information technology to improve patient safety.
HEC Forum. 2008;20(3):243-58. doi:10.1007/s10730-008-9074-5.
https://psnet.ahrq.gov/issue/ethic…
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psnet.ahrq.gov/node/41484/psn-pdf
September 26, 2012 - An institution-wide handoff task force to standardise and
improve physician handoffs.
September 26, 2012
Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve
physician handoffs. BMJ Qual Saf. 2012;21(10):863-71.
https://psnet.ahrq.gov/issue/institution-wide-ha…
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psnet.ahrq.gov/node/40658/psn-pdf
August 03, 2011 - Development and validation of a tool to improve
paediatric referral/consultation communication.
August 3, 2011
Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric
referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. doi:10.1136/bmjqs.2010.045781.
https:…
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psnet.ahrq.gov/node/41048/psn-pdf
November 04, 2012 - An educational intervention to increase "speaking-up"
behaviors in nurses and improve patient safety.
November 4, 2012
Sayre MM, McNeese-Smith D, Leach LS, et al. An educational intervention to increase "speaking-up"
behaviors in nurses and improve patient safety. J Nurs Care Qual. 2012;27(2):154-60.
doi:10.1097/N…
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psnet.ahrq.gov/node/42553/psn-pdf
January 07, 2014 - Learning in action: developing safety improvement
capabilities through action learning.
January 7, 2014
Christiansen A, Prescott T, Ball J. Learning in action: developing safety improvement capabilities through
action learning. Nurse Educ Today. 2014;34(2):243-7. doi:10.1016/j.nedt.2013.07.008.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/45478/psn-pdf
October 26, 2016 - Core principles of quality improvement and patient safety.
October 26, 2016
Bartman T, McClead RE. Core Principles of Quality Improvement and Patient Safety. Pediatr Rev.
2016;37(10):407-417.
https://psnet.ahrq.gov/issue/core-principles-quality-improvement-and-patient-safety
This review discusses key patient safet…
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psnet.ahrq.gov/node/36049/psn-pdf
January 02, 2017 - Improving health care quality and safety for people with
disabilities: an interview with Lisa Iezzoni.
January 2, 2017
Iezzoni LI. Improving health care quality and safety for people with disabilities: an interview with Lisa
Iezzoni. Interview by Steven Berman. Jt Comm J Qual Patient Saf. 2006;32(7):400-6, 357.
ht…
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psnet.ahrq.gov/node/42224/psn-pdf
April 24, 2013 - Top 10 ways to improve patient safety now.
April 24, 2013
O'Reilly KB.
https://psnet.ahrq.gov/issue/top-10-ways-improve-patient-safety-now
This news article highlights patient safety improvement strategies covered in the AHRQ Making Health
Care Safer II report.
https://psnet.ahrq.gov/issue/top-10-ways-improve-pat…
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psnet.ahrq.gov/node/38395/psn-pdf
January 02, 2017 - Reducing medication errors and improving systems
reliability using an electronic medication reconciliation
system.
January 2, 2017
Agrawal A, Wu WY. Reducing Medication Errors and Improving Systems Reliability Using an Electronic
Medication Reconciliation System. The Joint Commission Journal on Quality and Patient…
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psnet.ahrq.gov/node/43494/psn-pdf
November 17, 2014 - Read-back improves information transfer in simulated
clinical crises.
November 17, 2014
Boyd M, Cumin D, Lombard B, et al. Read-back improves information transfer in simulated clinical crises.
BMJ Qual Saf. 2014;23(12):989-93. doi:10.1136/bmjqs-2014-003096.
https://psnet.ahrq.gov/issue/read-back-improves-informati…
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psnet.ahrq.gov/node/38316/psn-pdf
March 04, 2009 - Practising open disclosure: clinical incident
communication and systems improvement.
March 4, 2009
Iedema R, Jorm C, Wakefield J, et al. Practising Open Disclosure: clinical incident communication and
systems improvement. Sociol Health Illn. 2009;31(2):262-77. doi:10.1111/j.1467-9566.2008.01131.x.
https://psnet.ah…
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psnet.ahrq.gov/node/41641/psn-pdf
August 29, 2012 - Patient safety and quality improvement: an overview of
QI.
August 29, 2012
Schriefer J, Leonard M. Patient safety and quality improvement: an overview of QI. Pediatr Rev.
2012;33(8):353-9; quiz 359-60. doi:10.1542/pir.33-8-353.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-overview-qi
This c…
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psnet.ahrq.gov/node/39863/psn-pdf
January 04, 2011 - Improving the quality of drug error reporting.
January 4, 2011
Armitage G, Newell R, Wright J. Improving the quality of drug error reporting. J Eval Clin Pract.
2010;16(6):1189-97. doi:10.1111/j.1365-2753.2009.01293.x.
https://psnet.ahrq.gov/issue/improving-quality-drug-error-reporting
This analysis of voluntarily…
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psnet.ahrq.gov/node/40374/psn-pdf
April 13, 2011 - Better off not knowing: improving clinical care by limiting
physician access to unsolicited diagnostic information.
April 13, 2011
Volk ML, Ubel PA. Better off not knowing: improving clinical care by limiting physician access to unsolicited
diagnostic information. Arch Intern Med. 2011;171(6):487-8. doi:10.1001/arc…
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psnet.ahrq.gov/node/36050/psn-pdf
January 02, 2017 - Improving the safety of intravenous admixtures: lessons
learned from a Pentostam® overdose.
January 2, 2017
Just S, Schepers G, Piotrowski MM, et al. Improving the safety of intravenous admixtures: lessons learned
from a Pentostam overdose. Jt Comm J Qual Patient Saf. 2006;32(7):366-72.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/35989/psn-pdf
September 17, 2010 - Using preprinted medication order forms to improve the
safety of investigational drug use.
September 17, 2010
Tamer H, Shehab N. Using preprinted medication order forms to improve the safety of investigational drug
use. Am J Health Syst Pharm. 2006;63(11):1022, 1025-1026, 1028.
https://psnet.ahrq.gov/issue/using-p…
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - EMERGING INNOVATIONS
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children
Citation Text:
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
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psnet.ahrq.gov/issue/effects-efforts-optimise-morbidity-and-mortality-rounds-serve-contemporary-quality
July 19, 2019 - Review
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Citation Text:
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to serve contem…