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psnet.ahrq.gov/node/60985/psn-pdf
October 07, 2020 - Rapid-cycle improvement during the COVID-19 pandemic:
using safety reports to inform incident command.
October 7, 2020
Desai S, Eappen S, Murray K, et al. Rapid-cycle improvement during the COVID-19 pandemic: using safety
reports to inform incident command. Jt Comm J Qual Patient Saf. 2020;46(12):715-714.
doi:10.1…
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psnet.ahrq.gov/node/43175/psn-pdf
December 12, 2014 - Interventions to improve safe and effective medicines use
by consumers: an overview of systematic reviews.
December 12, 2014
Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by
consumers: an overview of systematic reviews. Cochrane Database Syst Rev. 2014;(4):CD007768.
d…
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psnet.ahrq.gov/node/40704/psn-pdf
August 17, 2011 - Plan for quality to improve patient safety at the point of
care.
August 17, 2011
Ehrmeyer SS. Plan for Quality to Improve Patient Safety at the Point of Care. Ann Saudi Med. 2011;31(4).
doi:10.4103/0256-4947.83203.
https://psnet.ahrq.gov/issue/plan-quality-improve-patient-safety-point-care
This review discusses t…
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psnet.ahrq.gov/node/36598/psn-pdf
June 30, 2011 - E-prescribing first step to improved safety.
June 30, 2011
Finkelstein JB. E-prescribing first step to improved safety. Journal of the National Cancer Institute.
2006;98(24):1763-5.
https://psnet.ahrq.gov/issue/e-prescribing-first-step-improved-safety
This article discusses changes implemented at Dana-Farber Cance…
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psnet.ahrq.gov/node/35472/psn-pdf
September 21, 2009 - Clinical alarms: improving efficiency and effectiveness.
September 21, 2009
Phillips J, Barnsteiner JH. Clinical alarms: improving efficiency and effectiveness. Crit Care Nurs Q.
2005;28(4):317-323.
https://psnet.ahrq.gov/issue/clinical-alarms-improving-efficiency-and-effectiveness
The authors outline a process fo…
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psnet.ahrq.gov/node/35600/psn-pdf
June 21, 2010 - Improving nursing unit teamwork.
June 21, 2010
Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550-556.
doi:10.1097/00005110-200512000-00009.
https://psnet.ahrq.gov/issue/improving-nursing-unit-teamwork
The authors share several strategies for improving teamwork among nurses, includ…
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psnet.ahrq.gov/issue/experiences-lean-six-sigma-improvement-strategy-reduce-parenteral-medication-administration
October 13, 2021 - Commentary
Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm.
Citation Text:
van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to reduce pa…
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psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model
June 29, 2009 - Commentary
Using incident reporting to improve patient safety: a conceptual model.
Citation Text:
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
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psnet.ahrq.gov/issue/national-pediatric-anesthesia-safety-quality-improvement-program-united-states
March 03, 2011 - Study
National pediatric anesthesia safety quality improvement program in the United States.
Citation Text:
Kurth D, Tyler D, Heitmiller ES, et al. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014;119(1):112-21. doi:10.1213/ANE.000…
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psnet.ahrq.gov/issue/safer-delivery-surgical-services-programme-controlled-and-after-intervention-studies-pre
October 12, 2016 - Book/Report
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis.
Citation Text:
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Poo…
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psnet.ahrq.gov/issue/preventable-harm-index-effective-motivator-facilitate-drive-zero
January 15, 2014 - Commentary
The Preventable Harm Index: an effective motivator to facilitate the drive to zero.
Citation Text:
Brilli RJ, McClead RE, Davis T, et al. The Preventable Harm Index: an effective motivator to facilitate the drive to zero. J Pediatr. 2010;157(4):681-3. doi:10.1016/j.jpeds.201…
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psnet.ahrq.gov/issue/executivesenior-leader-checklist-improve-culture-and-reduce-central-line-associated
August 25, 2010 - Commentary
Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.
Citation Text:
Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Executive/Senior Leader Checklist to improve culture and reduce central line-associated bloodstream…
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psnet.ahrq.gov/issue/latent-risk-assessment-tool-health-care-leaders
September 05, 2018 - Commentary
Latent risk assessment tool for health care leaders.
Citation Text:
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.
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DOI Google S…
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psnet.ahrq.gov/issue/armstrong-institute-academic-institute-patient-safety-and-quality-improvement-research
September 27, 2017 - Commentary
The Armstrong Institute: an academic institute for patient safety and quality improvement, research, training, and practice.
Citation Text:
Pronovost P, Holzmueller CG, Molello NE, et al. The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement…
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psnet.ahrq.gov/issue/checking-all-boxes-checklist-when-and-how-use-checklists-effectively
June 29, 2022 - Commentary
Checking all the boxes: a checklist for when and how to use checklists effectively.
Citation Text:
Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bm…
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psnet.ahrq.gov/issue/ten-strategies-improve-management-abnormal-test-result-alerts-electronic-health-record
April 14, 2011 - Commentary
Ten strategies to improve management of abnormal test result alerts in the electronic health record.
Citation Text:
Singh H, Wilson L, Reis B, et al. Ten strategies to improve management of abnormal test result alerts in the electronic health record. J Patient Saf. 2010;6(2)…
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psnet.ahrq.gov/issue/state-science-and-future-directions-improve-diagnostic-safety-older-adults
January 22, 2025 - Book/Report
State of the Science and Future Directions to Improve Diagnostic Safety in Older Adults.
Citation Text:
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic Safety In Older Adults. Rockville, MD: Agency for Healthcare Research a…
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psnet.ahrq.gov/issue/improving-safety-culture-adult-medical-units-through-multidisciplinary-teamwork-and
February 18, 2011 - Study
Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.
Citation Text:
Blegen MA, Sehgal NL, Alldredge BK, et al. Improving safety culture on adult medical units through multidisciplinary teamwork and c…
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psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it
June 03, 2010 - Commentary
Classic
The tension between needing to improve care and knowing how to do it.
Citation Text:
Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608-13.
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psnet.ahrq.gov/issue/quality-improvement-approach-standardization-and-sustainability-hand-process
May 15, 2019 - Commentary
A quality improvement approach to standardization and sustainability of the hand-off process.
Citation Text:
Fryman C, Hamo C, Raghavan S, et al. A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017;6(1). doi:1…