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psnet.ahrq.gov/node/42701/psn-pdf
June 27, 2018 - Improving reliability with root cause analysis.
June 27, 2018
Latino RJ
https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
This article relates how root cause analysis, typically used after an adverse event, can be utilized as a
proactive risk assessment tool to enhance reliability.
https://ps…
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psnet.ahrq.gov/node/36092/psn-pdf
March 18, 2010 - Improving the safety of telephone or verbal orders.
March 18, 2010
PA-PSRS Patient Saf Advis. 2006 Jun;3(2):1,3-7.
https://psnet.ahrq.gov/issue/improving-safety-telephone-or-verbal-orders
This article shares several examples of errors made while verbally communicating medication orders and
includes recommendations…
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psnet.ahrq.gov/node/37069/psn-pdf
December 20, 2007 - Standardising wristbands improves patient safety.
December 20, 2007
National Patient Safety Agency. Safer Practice Notice. July 2007;(24):1-2.
https://psnet.ahrq.gov/issue/standardising-wristbands-improves-patient-safety
This notice highlights the importance of standardizing wristband design and information to make…
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psnet.ahrq.gov/node/35320/psn-pdf
September 14, 2005 - How business intelligence can improve patient safety.
September 14, 2005
Wanless S, McManaway J. Metaphor Analytics. August 30, 2005.
https://psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
This article illustrates how hospitals can use their own administrative and patient data to reduce h…
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - National Patient Safety Goals
March 27, 2024
Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/national-patient-safety-goals
Background
Despite the development and publication of effective and evidence-based strategies to enhance patient
safety and reduce preventable h…
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…
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psnet.ahrq.gov/node/40077/psn-pdf
July 10, 2012 - Improvement Cymru.
July 10, 2012
NHS Wales.
https://psnet.ahrq.gov/issue/improvement-cymru
This national program draws from other large collaborative efforts to engage health care organizations
across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35753/psn-pdf
April 29, 2018 - IV vincristine survey shows safety improvements needed.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. February 23, 2006.
https://psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed
This article summarizes intravenous vincristine safety practices collected from more than 40…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/node/35579/psn-pdf
November 26, 2008 - Perioperative Issues for Surgeons: Improving Patient
Safety and Outcomes.
November 26, 2008
Napolitano LM, ed. Surg Clin North Am. 2005;85(6):1061-1380.
https://psnet.ahrq.gov/issue/perioperative-issues-surgeons-improving-patient-safety-and-outcomes
This issue focuses on the safety of surgical patients, with artic…
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psnet.ahrq.gov/node/34582/psn-pdf
November 15, 2011 - Improving Health Care.
November 15, 2011
Schiff G
https://psnet.ahrq.gov/issue/improving-health-care
Quality and honesty play an influential role in the safety and cost of medical care. Gordon Schiff, the
director of clinical and quality research (Department of Medicine at Stoger Hospital, Chicago, Illinois),
exp…
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psnet.ahrq.gov/node/34120/psn-pdf
December 30, 2012 - Strategies for Hospitals to Improve Patient Safety: A
Review of the Literature.
December 30, 2012
Wong J, Beglaryan H. Toronto, ON: The Change Foundation; February 2004.
https://psnet.ahrq.gov/issue/strategies-hospitals-improve-patient-safety-review-literature
A literature review of preventable adverse events in a…
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psnet.ahrq.gov/node/35491/psn-pdf
July 12, 2018 - Battling the obstetric malpractice crisis: improving
patient safety, part 1.
July 12, 2018
Bernstein PS. Medscape Ob/Gyn. October 31, 2005.
https://psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-1
The author emphasizes the complexity of decision making in obstetric care to…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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psnet.ahrq.gov/node/45858/psn-pdf
March 24, 2017 - From board to bedside: how the application of financial
structures to safety and quality can drive accountability in
a large health care system.
March 24, 2017
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures
to Safety and Quality Can Drive Accountability i…
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psnet.ahrq.gov/node/46471/psn-pdf
March 20, 2018 - Diagnostic errors in primary care pediatrics: Project
RedDE.
March 20, 2018
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds.
2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
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psnet.ahrq.gov/node/40239/psn-pdf
February 23, 2011 - Randomized trial of a warfarin communication protocol
for nursing homes: an SBAR-based approach.
February 23, 2011
Field T, Tjia J, Mazor KM, et al. Randomized trial of a warfarin communication protocol for nursing homes:
an SBAR-based approach. Am J Med. 2011;124(2):179.e1-7. doi:10.1016/j.amjmed.2010.09.017.
htt…
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psnet.ahrq.gov/node/37842/psn-pdf
November 20, 2017 - An epistemology of patient safety research: a framework
for study design and interpretation.
November 20, 2017
Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design
and interpretation. Part 4. One size does not fit all. Quality and Safety in Health Care. 2008;17(…
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psnet.ahrq.gov/node/46173/psn-pdf
August 20, 2018 - Advances in Patient Safety and Medical Liability.
August 20, 2018
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality;
2017. AHRQ Publication No. 17-0017-EF.
https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability
This publication describes the re…