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psnet.ahrq.gov/issue/target-focused-medical-emergency-team-training-using-human-patient-simulator-effects
May 23, 2013 - Study
Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude.
Citation Text:
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human patient simulator: effects on behaviour and atti…
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psnet.ahrq.gov/issue/effects-multicentre-teamwork-and-communication-programme-patient-outcomes-results-triad
January 16, 2013 - Study
Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.
Citation Text:
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication programme on patient o…
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psnet.ahrq.gov/issue/patient-feedback-safety-improvement-primary-care-results-feasibility-study
December 02, 2020 - Study
Patient feedback for safety improvement in primary care: results from a feasibility study.
Citation Text:
Hernan AL, Giles SJ, Beks H, et al. Patient feedback for safety improvement in primary care: results from a feasibility study. BMJ Open. 2020;10(6):e037887. doi:10.1136/bmjopen…
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psnet.ahrq.gov/issue/evaluation-and-mitigation-limitations-large-language-models-clinical-decision-making
March 09, 2022 - Commentary
Evaluation and mitigation of the limitations of large language models in clinical decision-making.
Citation Text:
Hager P, Jungmann F, Holland R, et al. Evaluation and mitigation of the limitations of large language models in clinical decision-making. Nat Med. 2024;30(9):2613-…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/impact-simulation-based-closed-loop-communication-training-medical-errors-pediatric-emergency
July 22, 2020 - Study
Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.
Citation Text:
Diaz MCG, Dawson K. Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department. Am J Med Qual…
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psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-within-health-care-systematic-review-past-decade
March 05, 2010 - Review
Classic
Interventions to improve team effectiveness within health care: a systematic review of the past decade.
Citation Text:
Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systemati…
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psnet.ahrq.gov/issue/changing-hospital-organisational-culture-improved-patient-outcomes-developing-and
June 17, 2020 - Study
Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.
Citation Text:
Linnander EL, McNatt Z, Boehmer K, et al. Changing hospital organisational culture for improved patient outcomes: developing a…
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psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching-university
November 07, 2018 - Commentary
Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.
Citation Text:
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more…
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psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure-mode-effect-analysis
December 09, 2020 - Study
High rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses.
Citation Text:
Öhrn A, Ericsson C, Andersson C, et al. High Rate of Implementation of Proposed Actions for Improvement With the Healt…
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psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
August 08, 2018 - Study
Detecting unapproved abbreviations in the electronic medical record.
Citation Text:
Capraro A, Stack AM, Harper MB, et al. Detecting unapproved abbreviations in the electronic medical record. Jt Comm J Qual Patient Saf. 2012;38(4):178-183. doi:10.1016/s1553-7250(12)38023-9.
Copy …
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psnet.ahrq.gov/node/36756/psn-pdf
March 28, 2007 - Improving Patient Safety.
March 28, 2007
Home Healthc Nurs. 2007;25(3):125-224.
https://psnet.ahrq.gov/issue/improving-patient-safety
This special issue includes articles that discuss the safety of home-based medical care.
https://psnet.ahrq.gov/issue/improving-patient-safety
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - no impact on care. 1 The impetus for change was reporting by the news media that made it clear that improvements
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-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. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/node/861882/psn-pdf
January 31, 2024 - Patient Safety in Office-Based Care Settings
January 31, 2024
Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
The Institute of Medicine’s 2000 publication To Err Is Human summarized res…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/node/41626/psn-pdf
August 29, 2012 - Impact of resident participation in surgical operations on
postoperative outcomes: National Surgical Quality
Improvement Program.
August 29, 2012
Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on
Postoperative Outcomes. Ann Surg. 2012;256(3):469-475. doi:10.1097/sl…
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psnet.ahrq.gov/node/43329/psn-pdf
July 09, 2014 - Facilitating a safe transition from the pediatric emergency
department to home with a post-discharge phone call: a
quality-improvement initiative to improve patient safety.
July 9, 2014
Bucaro PJ, Black E. Facilitating a safe transition from the pediatric emergency department to home with a
post-discharge phone ca…