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psnet.ahrq.gov/node/38592/psn-pdf
April 29, 2009 - The teaching of a structured tool improves the clarity and
content of interprofessional clinical communication.
April 29, 2009
Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of
interprofessional clinical communication. Qual Saf Health Care. 2009;18(2):137-40.
…
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psnet.ahrq.gov/node/41755/psn-pdf
October 10, 2012 - Utah Tenth Anniversary (2001–2011) Patient Safety
Report: Identifying Opportunities for Improvement.
October 10, 2012
Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.
https://psnet.ahrq.gov/issue/utah-tenth-anniversary-2001-2011-patient-safety-report-identifying-
oppor…
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psnet.ahrq.gov/node/41994/psn-pdf
March 11, 2013 - Does training with human patient simulation translate to
improved patient safety and outcome?
March 11, 2013
Shear TD, Greenberg SB, Tokarczyk A. Does training with human patient simulation translate to improved
patient safety and outcome? Curr Opin Anaesthesiol. 2013;26(2):159-63.
doi:10.1097/ACO.0b013e32835dc0af…
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psnet.ahrq.gov/node/46305/psn-pdf
September 27, 2017 - Using simulation to improve systems.
September 27, 2017
Kearney JA, Deutsch ES. Using Simulation to Improve Systems. Otolaryngol Clin North Am.
2017;50(5):1015-1028. doi:10.1016/j.otc.2017.05.011.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems-0
Simulations in health care can help uncover technical …
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psnet.ahrq.gov/node/40747/psn-pdf
September 07, 2011 - Misdiagnosis: analysis based on case record review with
proposals aimed to improve diagnostic processes.
September 7, 2011
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed
to improve diagnostic processes. Clin Med (Lond). 2011;11(4):317-321.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/60810/psn-pdf
August 12, 2020 - Hospitals Can Take Key Steps to Improve Safe Use of
Digital Systems.
August 12, 2020
Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.
https://psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems
Tracking problems with health information technology (Health IT) is an important st…
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psnet.ahrq.gov/node/45155/psn-pdf
May 25, 2016 - Interdisciplinary ICU cardiac arrest debriefing improves
survival outcomes.
May 25, 2016
Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival
outcomes*. Crit Care Med. 2014;42(7):1688-95. doi:10.1097/CCM.0000000000000327.
https://psnet.ahrq.gov/issue/interdiscipli…
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psnet.ahrq.gov/node/45590/psn-pdf
August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017.
August 2, 2017
Washington, DC: National Quality Forum; October 2016.
https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017
The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable
diagnosis. This we…
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psnet.ahrq.gov/node/36841/psn-pdf
December 31, 2014 - Using medical malpractice closed claims data to reduce
surgical risk and improve patient safety.
December 31, 2014
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and
improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
https://psnet.ahrq.gov/issue/using-medica…
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psnet.ahrq.gov/node/35859/psn-pdf
July 22, 2010 - A multifaceted approach to improve patient safety,
prevent medical errors and resolve the professional
liability crisis.
July 22, 2010
Weinstein L. A multifacited approach to improve patient safety, prevent medical errors and resolve the
professional liability crisis. Am J Obstet Gynecol. 2006;194(4):1160-5; discu…
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psnet.ahrq.gov/node/839330/psn-pdf
November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality.
November 2, 2022
Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine,
21e. New York, NY: McGraw Hill; 2022
https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
The task of performing a …
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psnet.ahrq.gov/node/38885/psn-pdf
August 19, 2009 - Patient safety: Part II. Opportunities for improvement in
patient safety.
August 19, 2009
Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in
patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.jaad.2009.04.055.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/38824/psn-pdf
March 04, 2011 - Evaluation of a physician informatics tool to improve
patient handoffs.
March 4, 2011
Flanagan ME, Patterson ES, Frankel RM, et al. Evaluation of a physician informatics tool to improve patient
handoffs. J Am Med Inform Assoc. 2009;16(4):509-15. doi:10.1197/jamia.M2892.
https://psnet.ahrq.gov/issue/evaluation-phys…
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psnet.ahrq.gov/node/38361/psn-pdf
January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue,
improve patient safety.
January 31, 2011
Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA.
2009;301(3):259-61. doi:10.1001/jama.2008.940.
https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…
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psnet.ahrq.gov/node/38507/psn-pdf
February 10, 2015 - From tasks to processes: the case for changing health
information technology to improve health care.
February 10, 2015
Walker JM, Carayon P. From tasks to processes: the case for changing health information technology to
improve health care. Health Aff (Millwood). 2009;28(2):467-477. doi:10.1377/hlthaff.28.2.467.
…
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psnet.ahrq.gov/node/41762/psn-pdf
May 03, 2017 - Improving the Measurement of Surgical Site Infection
Risk Stratification/Outcome Detection: Final Contract
Report.
May 3, 2017
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ
Publication No. 12-0046-EF.
https://psnet.ahrq.gov/issue/improving-measurement-surgical-si…
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psnet.ahrq.gov/node/40943/psn-pdf
September 26, 2012 - Getting the message: a quality improvement initiative to
reduce pages sent to the wrong physician.
September 26, 2012
Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce
pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):855-62.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/38913/psn-pdf
May 24, 2015 - Thinking Outside the Pillbox: A System-wide Approach to
Improving Patient Medication Adherence for Chronic
Disease.
May 24, 2015
Cambridge, MA: New England Healthcare Institute; August 12, 2009.
https://psnet.ahrq.gov/issue/thinking-outside-pillbox-system-wide-approach-improving-patient-medication-
adherence-chro…
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psnet.ahrq.gov/node/40727/psn-pdf
October 21, 2011 - Saving lives by studying deaths: using standardized
mortality reviews to improve inpatient safety.
October 21, 2011
Lau H, Litman KC. Saving lives by studying deaths: using standardized mortality reviews to improve
inpatient safety. Jt Comm J Qual Patient Saf. 2011;37(9):400-408.
https://psnet.ahrq.gov/issue/savin…
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psnet.ahrq.gov/node/44487/psn-pdf
September 23, 2015 - Patient safety and quality improvement: terminology.
September 23, 2015
Pereira-Argenziano L, Levy FH. Patient Safety and Quality Improvement: Terminology. Pediatr Rev.
2015;36(9):403-11; quiz 412-3. doi:10.1542/pir.36-9-403.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-terminology
To Err Is…