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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
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psnet.ahrq.gov/issue/comprehensive-obstetrics-patient-safety-program-improves-safety-climate-and-culture
October 20, 2014 - Study
A comprehensive obstetrics patient safety program improves safety climate and culture.
Citation Text:
Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol. 2011;204(3):216.e1-6. doi:10.1016/…
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psnet.ahrq.gov/issue/use-technology-improve-adherence-surgical-safety-checklists-operating-room
December 03, 2014 - Study
Use of technology to improve the adherence to surgical safety checklists in the operating room.
Citation Text:
Pati AB, Mishra TS, Chappity P, et al. Use of technology to improve the adherence to surgical safety checklists in the operating room. Jt Comm J Qual Patient Saf. 2023;49(…
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psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial
October 21, 2010 - Study
A visual medication schedule to improve anticoagulation control: a randomized, controlled trial.
Citation Text:
Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;…
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psnet.ahrq.gov/issue/clinical-faculty-taking-lead-teaching-quality-improvement-and-patient-safety
July 01, 2017 - Commentary
Clinical faculty: taking the lead in teaching quality improvement and patient safety.
Citation Text:
Davis NL, Davis DA, Rayburn WF. Clinical faculty: taking the lead in teaching quality improvement and patient safety. Am J Obstet Gynecol. 2014;211(3):215-215.e1. doi:10.1016/j…
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psnet.ahrq.gov/issue/diagnostic-delays-and-errors-head-and-neck-cancer-patients-opportunities-improvement
March 14, 2022 - Study
Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement.
Citation Text:
Franco J, Elghouche AN, Harris MS, et al. Diagnostic Delays and Errors in Head and Neck Cancer Patients: Opportunities for Improvement. Am J Med Qual. 2017;32(3):330-335. do…
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psnet.ahrq.gov/issue/stories-clinicians-tell-achieving-high-reliability-and-improving-patient-safety
April 24, 2018 - Commentary
The stories clinicians tell: achieving high reliability and improving patient safety.
Citation Text:
Cohen DL, Stewart KO. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety. Perm J. 2016;20(1):85-90. doi:10.7812/TPP/15-039.
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psnet.ahrq.gov/issue/inpatient-notes-just-what-doctor-ordered-checklists-improve-diagnosis
August 14, 2019 - Commentary
Inpatient notes: just what the doctor ordered—checklists to improve diagnosis.
Citation Text:
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.…
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psnet.ahrq.gov/issue/improving-disclosure-and-management-medical-error-opportunity-transform-surgeons-tomorrow
April 11, 2012 - Review
Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.
Citation Text:
Tevlin R, Doherty E, Traynor O. Improving disclosure and management of medical error - an opportunity to transform the surgeons of tomorrow. Surgeon. 2013;11…
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psnet.ahrq.gov/issue/communication-critical-care-environments-mobile-telephones-improve-patient-care
June 27, 2018 - Study
Communication in critical care environments: mobile telephones improve patient care.
Citation Text:
Soto RG, Chu LF, Goldman JM, et al. Communication in critical care environments: mobile telephones improve patient care. Anesth Analg. 2006;102(2):535-41.
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psnet.ahrq.gov/issue/what-words-convey-potential-patient-narratives-inform-quality-improvement
August 19, 2015 - Study
What words convey: the potential for patient narratives to inform quality improvement.
Citation Text:
Grob R, Schlesinger M, Barre LR, et al. What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement. Milbank Q. 2019;97(1):176-227. doi:10.1111/1468-0009.…
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psnet.ahrq.gov/issue/improving-safety-and-eliminating-redundant-tests-cutting-costs-us-hospitals
May 27, 2011 - Study
Classic
Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals.
Citation Text:
Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(…
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psnet.ahrq.gov/issue/simulation-tool-improve-safety-pre-hospital-anaesthesia-pilot-study
October 19, 2022 - Study
Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.
Citation Text:
Batchelder AJ, Steel A, Mackenzie R, et al. Simulation as a tool to improve the safety of pre-hospital anaesthesia--a pilot study. Anaesthesia. 2009;64(9):978-83. doi:10.1111/j.1365…
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psnet.ahrq.gov/issue/managing-patient-access-and-flow-emergency-department-improve-patient-safety
April 16, 2018 - Newspaper/Magazine Article
Managing patient access and flow in the emergency department to improve patient safety.
Citation Text:
Managing patient access and flow in the emergency department to improve patient safety. PA-PSRS Patient Saf Advis. 2010;7:123-134.
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psnet.ahrq.gov/issue/reducing-retained-foreign-objects-operating-room-quality-improvement-initiative
April 19, 2023 - Study
Reducing retained foreign objects in the operating room: a quality improvement initiative.
Citation Text:
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.10…
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psnet.ahrq.gov/issue/feedback-incident-reporting-information-and-action-improve-patient-safety
August 26, 2009 - Study
Feedback from incident reporting: information and action to improve patient safety.
Citation Text:
Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18(1):11-21. doi:10.1136/qshc.2…
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psnet.ahrq.gov/issue/teaching-structured-tool-improves-clarity-and-content-interprofessional-clinical
June 28, 2017 - Study
The teaching of a structured tool improves the clarity and content of interprofessional clinical communication.
Citation Text:
Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual …
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/44597/psn-pdf
October 28, 2015 - Smarter clinical checklists: how to minimize checklist
fatigue and maximize clinician performance.
October 28, 2015
Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician
Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352.
https://psnet.ahrq.gov/…