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psnet.ahrq.gov/node/44767/psn-pdf
January 20, 2016 - "What's psychology got to do with it?" Applying
psychological theory to understanding failures in modern
healthcare settings.
January 20, 2016
Rydon-Grange M. 'What's Psychology got to do with it?' Applying psychological theory to understanding
failures in modern healthcare settings. J Med Ethics. 2015;41(11):880-…
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psnet.ahrq.gov/node/38470/psn-pdf
March 11, 2009 - Quality and strength of patient safety climate on
medical–surgical units.
March 11, 2009
Hughes LC, Chang YK, Mark BA. Quality and strength of patient safety climate on medical-surgical units.
Health Care Manag Rev. 2009;34(1):19-28. doi:10.1097/01.HMR.0000342976.07179.3a.
https://psnet.ahrq.gov/issue/quality-and-…
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psnet.ahrq.gov/node/867229/psn-pdf
January 01, 2025 - Feasibility of prospective error reporting in home
palliative care: a mixed methods study.
December 4, 2024
Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a
mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692163241288774.
https://psnet.ahr…
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psnet.ahrq.gov/node/47059/psn-pdf
May 16, 2018 - Participating in a multisite study exploring operational
failures encountered by frontline nurses: lessons learned.
May 16, 2018
Melnyk H, Rosenfeld P, Glassman KS. Participating in a Multisite Study Exploring Operational Failures
Encountered by Frontline Nurses: Lessons Learned. J Nurs Adm. 2018;48(4):203-208.
do…
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psnet.ahrq.gov/node/40994/psn-pdf
December 18, 2014 - Implementing medication reconciliation in outpatient
pediatrics.
December 18, 2014
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics.
Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
https://psnet.ahrq.gov/issue/implementing-medication-reconciliat…
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psnet.ahrq.gov/node/47022/psn-pdf
July 19, 2018 - Thoughtless design of the electronic health record drives
overuse, but purposeful design can nudge improved
patient care.
July 19, 2018
Vaughn VM, Linder JA. Thoughtless design of the electronic health record drives overuse, but purposeful
design can nudge improved patient care. BMJ Qual Saf. 2018;27(8):583-586. d…
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psnet.ahrq.gov/node/836984/psn-pdf
April 27, 2022 - A 6-year thematic review of reported incidents associated
with cardiopulmonary resuscitation calls in a United
Kingdom hospital.
April 27, 2022
Beed M, Hussain S, Woodier N, et al. A 6-year thematic review of reported incidents associated with
cardiopulmonary resuscitation calls in a United Kingdom hospital. J Pat…
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psnet.ahrq.gov/node/46794/psn-pdf
May 17, 2018 - Implementation of diagnostic pauses in the ambulatory
setting.
May 17, 2018
Huang GC, Kriegel G, Wheaton C, et al. Implementation of diagnostic pauses in the ambulatory setting.
BMJ Qual Saf. 2018;27(6):492-497. doi:10.1136/bmjqs-2017-007192.
https://psnet.ahrq.gov/issue/implementation-diagnostic-pauses-ambulatory…
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psnet.ahrq.gov/node/858164/psn-pdf
December 13, 2023 - Risk-adjusted cumulative sum for early detection of
hospitals with excess perioperative mortality.
December 13, 2023
Chen VW, Chidi AP, Dong Y, et al. Risk-adjusted cumulative sum for early detection of hospitals with
excess perioperative mortality. JAMA Surg. 2023;158(11):1176. doi:10.1001/jamasurg.2023.3673.
htt…
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psnet.ahrq.gov/node/861768/psn-pdf
January 31, 2024 - "We're all truly pulling in the exact same direction": A
qualitative study of attending and resident physician
impressions of structured bedside interdisciplinary
rounds.
January 31, 2024
Mastalerz KA, Jordan SR, Townsley N. “We're all truly pulling in the exact same direction”: a qualitative
study of attending a…
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psnet.ahrq.gov/node/866556/psn-pdf
August 21, 2024 - Digital maturity as a predictor of quality and safety
outcomes in US hospitals: cross-sectional observational
study.
August 21, 2024
Snowdon A, Hussein A, Danforth M, et al. Digital maturity as a predictor of quality and safety outcomes in
US hospitals: cross-sectional observational study. J Med Internet Res. 2024…
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psnet.ahrq.gov/node/37334/psn-pdf
February 01, 2011 - A framework for health care organizations to develop and
evaluate a safety scorecard.
February 1, 2011
Pronovost P, Berenholtz SM, Needham DM. A framework for health care organizations to develop and
evaluate a safety scorecard. JAMA. 2007;298(17):2063-5.
https://psnet.ahrq.gov/issue/framework-health-care-organiza…
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psnet.ahrq.gov/node/47537/psn-pdf
November 14, 2018 - Developing a learning health system: insights from a
qualitative process evaluation of a pharmacist-led
electronic audit and feedback intervention to improve
medication safety in primary care.
November 14, 2018
Jeffries M, Keers RN, Phipps D, et al. Developing a learning health system: Insights from a qualitative
…
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psnet.ahrq.gov/node/47962/psn-pdf
May 01, 2019 - Understanding the clinical implications of resident
involvement in uncommon operations.
May 1, 2019
Dasani SS, Simmons KD, Wirtalla CJ, et al. Understanding the Clinical Implications of Resident
Involvement in Uncommon Operations. J Surg Educ. 2019;76(5):1319-1328.
doi:10.1016/j.jsurg.2019.03.011.
https://psnet.a…
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psnet.ahrq.gov/node/45964/psn-pdf
March 22, 2017 - What is known: examining the empirical literature in
resident work hours using 30 influential articles.
March 22, 2017
Philibert I. What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential
Articles. J Grad Med Educ. 2016;8(5):795-805. doi:10.4300/JGME-D-16-00642.1.
https://psne…
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psnet.ahrq.gov/node/866636/psn-pdf
January 01, 2025 - Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals.
September 4, 2024
Campione Russo A, Tilly J?L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13485.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47867/psn-pdf
June 19, 2019 - Increasing compliance of safe medication administration
in pediatric anesthesia by use of a standardized checklist.
June 19, 2019
Kanjia MK, Adler AC, Buck D, et al. Increasing compliance of safe medication administration in pediatric
anesthesia by use of a standardized checklist. Paediatr Anaesth. 2019;29(3):258-2…
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psnet.ahrq.gov/node/867596/psn-pdf
January 22, 2025 - Creation of root cause analysis and action (RCA2)
standard work by a multidisciplinary team to prevent
harm, reduce bias, and improve safety culture.
January 22, 2025
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work
by a multidisciplinary team to prevent harm,…
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psnet.ahrq.gov/node/40394/psn-pdf
January 01, 2019 - Partnership for Patients.
October 6, 2016
Washington, DC: US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/partnership-patients
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to
decrease preventable harm in United States hospitals.…
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psnet.ahrq.gov/node/72748/psn-pdf
February 17, 2021 - The Collective Leadership for Safety Culture (Co-Lead)
team intervention to promote teamwork and patient
safety.
February 17, 2021
De Brún A, Anjara S, Cunningham U, et al. The Collective Leadership for Safety Culture (Co-Lead) team
intervention to promote teamwork and patient safety. Int J Environ Res Public Heal…