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psnet.ahrq.gov/node/41946/psn-pdf
January 09, 2013 - Thirty-day outcomes support implementation of a surgical
safety checklist.
January 9, 2013
Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical
safety checklist. J Am Coll Surg. 2012;215(6):766-76. doi:10.1016/j.jamcollsurg.2012.07.015.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46673/psn-pdf
March 21, 2018 - Human factors and simulation in emergency medicine.
March 21, 2018
Hayden EM, Wong AH, Ackerman J, et al. Human Factors and Simulation in Emergency Medicine. Acad
Emerg Med. 2018;25(2):221-229. doi:10.1111/acem.13315.
https://psnet.ahrq.gov/issue/human-factors-and-simulation-emergency-medicine
Human factors engine…
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psnet.ahrq.gov/node/48144/psn-pdf
August 07, 2019 - Moving towards a Safety II approach.
August 7, 2019
Woodward S. Moving towards a safety II approach. J Patient Saf Risk Manag. 2019;24(3):96-99.
doi:10.1177/2516043519855264.
https://psnet.ahrq.gov/issue/moving-towards-safety-ii-approach
Efforts to improve patient safety have evolved beyond investigating what went…
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psnet.ahrq.gov/node/45777/psn-pdf
January 11, 2017 - Disclosure of adverse events in pediatrics.
January 11, 2017
McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management;
Council on Quality Improvement and Patient Safety. Pediatrics. 2016;138(6);e20163215.
https://psnet.ahrq.gov/issue/disclosure-adverse-events-pediatrics
Op…
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psnet.ahrq.gov/node/39547/psn-pdf
January 19, 2011 - The impact of a tele-ICU on provider attitudes about
teamwork and safety climate.
January 19, 2011
Chu-Weininger MYL, Wueste L, Lucke JF, et al. The impact of a tele-ICU on provider attitudes about
teamwork and safety climate. Qual Saf Health Care. 2010;19(6):e39. doi:10.1136/qshc.2007.024992.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45661/psn-pdf
November 09, 2016 - Center for Diagnostic Excellence.
November 9, 2016
Armstrong Institute for Patient Safety and Quality
https://psnet.ahrq.gov/issue/center-diagnostic-excellence
Diagnostic error has recently been recognized as a serious patient safety concern. Established within the
Armstrong Center for Patient Safety and Quality, …
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psnet.ahrq.gov/node/41583/psn-pdf
August 08, 2012 - Achieving the 'perfect handoff' in patient transfers:
building teamwork and trust.
August 8, 2012
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.1365-2834.2012.01400.x.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44576/psn-pdf
January 23, 2018 - Healthcare Quality and Patient Safety Award.
January 23, 2018
Iowa Healthcare Collaborative.
https://psnet.ahrq.gov/issue/healthcare-quality-and-patient-safety-award
This award seeks to recognize health care organizations and professionals that have exhibited leadership
and innovation in improving patient safety i…
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psnet.ahrq.gov/node/38213/psn-pdf
November 12, 2008 - AHRQ announces interest in research on diagnostic
errors in ambulatory care settings.
November 12, 2008
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007.
Publication No. NOT-HS-08-002.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
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psnet.ahrq.gov/node/47062/psn-pdf
October 13, 2018 - Latent risk assessment tool for health care leaders.
October 13, 2018
Paine LA, Holzmueller CG, Elliott R, et al. Latent risk assessment tool for health care leaders. J Healthc
Risk Manag. 2018;38(2):36-46. doi:10.1002/jhrm.21316.
https://psnet.ahrq.gov/issue/latent-risk-assessment-tool-health-care-leaders
Health …
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psnet.ahrq.gov/node/48106/psn-pdf
July 24, 2019 - Teamwork Toolkit.
July 24, 2019
Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019.
https://psnet.ahrq.gov/issue/teamwork-toolkit
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed
to help organizations create a culture that embeds teamwork…
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psnet.ahrq.gov/node/45229/psn-pdf
July 13, 2016 - The WakeWings journey: creating a patient safety
program.
July 13, 2016
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9.
doi:10.1016/j.aorn.2016.04.004.
https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
Successful and sustainable implementa…
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psnet.ahrq.gov/node/60565/psn-pdf
June 03, 2020 - The public has been forgiving. But hospitals got some
things wrong.
June 3, 2020
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May
21.
https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
The complexity of the COVID-19 crisis cr…
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psnet.ahrq.gov/node/72652/psn-pdf
January 20, 2021 - Textbook of Patient Safety and Clinical Risk Management.
January 20, 2021
Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Springer Nature: Cham Switzerland; 2021. ISBN
9783030594022.
https://psnet.ahrq.gov/issue/textbook-patient-safety-and-clinical-risk-management
Foundations and practical exp…
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psnet.ahrq.gov/node/72685/psn-pdf
January 27, 2021 - Human Factors and Ergonomics in Healthcare.
January 27, 2021
Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.
https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare
Human factors approaches have been identified as one of the primary vehicles to create las…
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psnet.ahrq.gov/node/41792/psn-pdf
November 21, 2012 - Systematic review of serious games for medical
education and surgical skills training.
November 21, 2012
Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and
surgical skills training. Br J Surg. 2012;99(10):1322-30. doi:10.1002/bjs.8819.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/60677/psn-pdf
July 08, 2020 - Optimizing patient safety through system strategies and
patient engagement.
July 8, 2020
Rooprai P, Mistry N. Patient Saf Qual Healthc. June 23, 2020.
https://psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
Health systems are complex environments that require integra…
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psnet.ahrq.gov/node/40198/psn-pdf
February 09, 2011 - Measures and measurement of high-performance work
systems in health care settings: propositions for
improvement.
February 9, 2011
Etchegaray J, St John C, Thomas EJ. Measures and measurement of high-performance work systems in
health care settings: Propositions for improvement. Health Care Manage Rev. 2011;36(1):3…
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psnet.ahrq.gov/node/849338/psn-pdf
May 24, 2023 - The impact of language barriers on patient care: a
pharmacy perspective.
May 24, 2023
Patel J. PM Healthcare Journal. Spring 2023(4):5-18.
https://psnet.ahrq.gov/issue/impact-language-barriers-patient-care-pharmacy-perspective
Language discordance is known to degrade medication safety. The article discusses an exa…
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psnet.ahrq.gov/node/45508/psn-pdf
September 28, 2016 - Surviving a bad diagnosis.
September 28, 2016
Hobson K. US News News and World Report. September 13, 2016.
https://psnet.ahrq.gov/issue/surviving-bad-diagnosis
Diagnostic error has recently gained recognition as an important patient safety concern. This news article
relates the experiences of patients who were mis…