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psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors
June 22, 2022 - Commentary
Surgical data recording technology: a solution to address medical errors?
Citation Text:
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433. doi:10.1097/sla.0000000000003510.
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psnet.ahrq.gov/issue/surgical-complications-and-their-implications-surgeons-well-being
December 04, 2016 - Study
Surgical complications and their implications for surgeons' well-being.
Citation Text:
Pinto A, Faiz O, Bicknell C, et al. Surgical complications and their implications for surgeons' well-being. Br J Surg. 2013;100(13):1748-55. doi:10.1002/bjs.9308.
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psnet.ahrq.gov/issue/learning-defects-enhance-morbidity-and-mortality-conferences
May 20, 2009 - Commentary
Learning from defects to enhance morbidity and mortality conferences.
Citation Text:
Berenholtz SM, Hartsell TL, Pronovost P. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192-5. doi:10.1177/1062860609332370.
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psnet.ahrq.gov/issue/tracing-foundations-conceptual-framework-patient-safety-ontology
March 23, 2011 - Commentary
Tracing the foundations of a conceptual framework for a patient safety ontology.
Citation Text:
Runciman WB, Baker GR, Michel P, et al. Tracing the foundations of a conceptual framework for a patient safety ontology. BMJ Qual Saf. 2010;19(6). doi:10.1136/qshc.2009.035147.
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psnet.ahrq.gov/issue/framework-direct-observation-performance-and-safety-healthcare
November 15, 2023 - Commentary
Framework for direct observation of performance and safety in healthcare.
Citation Text:
Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407.
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psnet.ahrq.gov/issue/reducing-diagnostic-error-through-medical-home-based-primary-care-reform
July 15, 2015 - Commentary
Reducing diagnostic error through medical home-based primary care reform.
Citation Text:
Singh H, Graber ML. Reducing diagnostic error through medical home-based primary care reform. JAMA. 2010;304(4):463-4. doi:10.1001/jama.2010.1035.
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psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
August 04, 2021 - Commentary
Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System.
Citation Text:
Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227.
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psnet.ahrq.gov/issue/implementing-handoff-communication
August 25, 2010 - Commentary
Implementing handoff communication.
Citation Text:
Ardoin KB, Broussard L. Implementing handoff communication. J Nurses Staff Dev. 2011;27(3):128-35. doi:10.1097/NND.0b013e318217b3dd.
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psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-harm-neonatal-intensive
December 15, 2021 - Commentary
Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit.
Citation Text:
Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit. Sedlock EW, Ottosen M, Nether …
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psnet.ahrq.gov/issue/lives-lost-lives-saved-updated-comparative-analysis-avoidable-deaths-hospitals-graded
July 09, 2019 - Book/Report
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Citation Text:
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group. Austin M, Derk J. Bal…
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-training-anesthesiology-where-are-we
October 13, 2018 - Review
Improving patient safety through simulation training in anesthesiology: where are we?
Citation Text:
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.…
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psnet.ahrq.gov/issue/collaborating-or-selling-patients-conceptual-framework-emergency-department-inpatient-handoff
December 21, 2017 - Commentary
Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations.
Citation Text:
Hilligoss B, Mansfield JA, Patterson ES, et al. Collaborating-or "Selling" Patients? A Conceptual Framework for Emergency Department-to-Inpati…
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psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-preventable
December 02, 2020 - Commentary
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.
Citation Text:
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. Kirby J, Cannon C, Darrah …
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psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
February 15, 2017 - Book/Report
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events.
Citation Text:
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
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psnet.ahrq.gov/issue/beyond-communication-role-standardized-protocols-changing-health-care-environment
October 12, 2011 - Study
Beyond communication: the role of standardized protocols in a changing health care environment.
Citation Text:
Vardaman JM, Cornell P, Gondo MB, et al. Beyond communication: the role of standardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37…
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psnet.ahrq.gov/issue/application-lean-thinking-health-care-issues-and-observations
May 28, 2015 - Commentary
Application of lean thinking to health care: issues and observations.
Citation Text:
Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care. 2009;21(5). doi:10.1093/intqhc/mzp036…
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psnet.ahrq.gov/issue/bad-stars-or-guiding-lights-learning-disasters-improve-patient-safety
June 08, 2011 - Commentary
Bad stars or guiding lights? Learning from disasters to improve patient safety.
Citation Text:
Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding lights? Learning from disasters to improve patient safety. Qual Saf Health Care. 2010;19(4):332-6. doi:10.1136/qshc.2008…
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psnet.ahrq.gov/issue/building-highway-quality-health-care
February 14, 2017 - Commentary
Building a highway to quality health care.
Citation Text:
Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6. doi:10.1097/PTS.0000000000000074.
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psnet.ahrq.gov/issue/improving-patient-safety-comparative-views-patient-safety-specialists-workforce-staff-and
March 23, 2011 - Study
Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.
Citation Text:
Braithwaite J, Westbrook MT, Robinson M, et al. Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.…
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psnet.ahrq.gov/issue/cmqcc-obstetric-sepsis-toolkit-update-patient-centered-approach-quality-improvement
August 21, 2024 - Commentary
CMQCC obstetric sepsis toolkit update: a patient-centered approach to quality improvement.
Citation Text:
Main EK, Nath R, Bauer ME. CMQCC obstetric sepsis toolkit update: a patient-centered approach to quality improvement. Semin Perinatol. 2024:151976. doi:10.1016/j.semperi.2…