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psnet.ahrq.gov/issue/assessing-hospital-safety-nights-and-weekends-swan-tool
September 28, 2010 - Commentary
Assessing hospital safety on nights and weekends: the SWAN tool.
Citation Text:
Shulkin DJ. Assessing hospital safety on nights and weekends: the SWAN tool. J Patient Saf. 2009;5(2):75-8. doi:10.1097/PTS.0b013e3181a5db10.
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psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary
October 23, 2019 - Book/Report
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Citation Text:
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016. Rockville, MD: Agency for Healthc…
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psnet.ahrq.gov/issue/whos-surgical-safety-checklist-being-hyped
February 07, 2018 - Commentary
Is WHO's surgical safety checklist being hyped?
Citation Text:
Urbach DR, Dimick JB, Haynes AB, et al. Is WHO's surgical safety checklist being hyped? BMJ. 2019;366:l4700. doi:10.1136/bmj.l4700.
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psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmissions-reduction-program
August 20, 2018 - Commentary
Unintended harm associated with the Hospital Readmissions Reduction Program.
Citation Text:
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA. 2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
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psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors
December 02, 2020 - Commentary
Can electronic clinical documentation help prevent diagnostic errors?
Citation Text:
Schiff G, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? New Engl J Med. 2010;362(12):1066-1069. doi:10.1056/NEJMp0911734.
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psnet.ahrq.gov/issue/barriers-and-facilitators-related-implementation-surgical-safety-checklists-systematic-review
December 05, 2018 - Review
Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.
Citation Text:
Bergs J, Lambrechts F, Simons P, et al. Barriers and facilitators related to the implementation of surgical safety checklists: a s…
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psnet.ahrq.gov/issue/attitudes-toward-large-scale-implementation-incident-reporting-system
March 23, 2011 - Study
Attitudes toward the large-scale implementation of an incident reporting system.
Citation Text:
Braithwaite J, Westbrook MT, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care. 2008;20(3):184-91. doi:10.1093/intqhc…
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psnet.ahrq.gov/issue/between-flags-implementing-rapid-response-system-scale
June 08, 2011 - Commentary
'Between the flags': implementing a rapid response system at scale.
Citation Text:
Hughes C, Pain C, Braithwaite J, et al. 'Between the flags': implementing a rapid response system at scale. BMJ Qual Saf. 2014;23(9):714-7. doi:10.1136/bmjqs-2014-002845.
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psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
January 09, 2025 - Tools/Toolkit
The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide.
Citation Text:
The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. Portland, OR: Oregon Patient Safety Commission; 2022.
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psnet.ahrq.gov/issue/reasons-accident-causation-model-application-adverse-events-acute-care
October 29, 2014 - Commentary
Reason's accident causation model: application to adverse events in acute care.
Citation Text:
Elliott M, Page K, Worrall-Carter L. Reason's accident causation model: application to adverse events in acute care. Contemp Nurse. 2012;43(1):22-8. doi:10.5172/conu.2012.43.1.22.
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psnet.ahrq.gov/issue/fall-prevention-hospitals-integrative-review
November 03, 2021 - Review
Fall prevention in hospitals: an integrative review.
Citation Text:
Spoelstra SL, Given BA, Given CW. Fall Prevention in Hospitals. Clin Nurs Res. 2011;21(1). doi:10.1177/1054773811418106.
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psnet.ahrq.gov/issue/what-nhs-safety-thermometer
November 02, 2016 - Commentary
What is the NHS Safety Thermometer?
Citation Text:
Power M, Stewart K, Brotherton A. What is the NHS Safety Thermometer? Clin Risk. 2012;18(5):163-169.
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psnet.ahrq.gov/issue/using-interactive-voice-response-system-improve-patient-safety-following-hospital-discharge
February 01, 2017 - Study
Using an interactive voice response system to improve patient safety following hospital discharge.
Citation Text:
Forster AJ, van Walraven C. Using an interactive voice response system to improve patient safety following hospital discharge. J Eval Clin Pract. 2007;13(3):346-51.
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psnet.ahrq.gov/issue/developing-quality-and-safety-curriculum-fellows-lessons-learned-neonatology-fellowship
August 30, 2023 - Commentary
Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program.
Citation Text:
Gupta M, Ringer S, Tess A, et al. Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program. Acad…
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psnet.ahrq.gov/issue/handoffs-and-communication-underappreciated-roles-situational-awareness-and-inattentional
February 01, 2003 - Commentary
Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.
Citation Text:
Gosbee JW. Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness. Clin Obstet Gynecol. 2010;53(3)…
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psnet.ahrq.gov/issue/attitudes-health-sciences-faculty-members-towards-interprofessional-teamwork-and-education
March 02, 2011 - Study
Attitudes of health sciences faculty members towards interprofessional teamwork and education.
Citation Text:
Curran VR, Sharpe D, Forristall J. Attitudes of health sciences faculty members towards interprofessional teamwork and education. Med Educ. 2007;41(9):892-896.
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psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-initiative
October 17, 2012 - Commentary
Promoting patient safety: results of a TeamSTEPPS initiative.
Citation Text:
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
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psnet.ahrq.gov/issue/achieving-perfect-handoff-patient-transfers-building-teamwork-and-trust
October 08, 2016 - Commentary
Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.
Citation Text:
Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-…
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psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
July 19, 2023 - Commentary
Understanding patient safety and quality outcome data.
Citation Text:
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse. 2018;38(6):58-66. doi:10.4037/ccn2018979.
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psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites
August 02, 2015 - Study
Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.
Citation Text:
Bisset GS, Crowe J. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Pediatr Radiol. 2014;44(5):552-7. doi:10.1007…