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psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
May 12, 2021 - Study
A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial.
Citation Text:
Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized c…
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psnet.ahrq.gov/issue/describing-evidence-linking-interprofessional-education-interventions-improving-delivery-safe
June 12, 2013 - Review
Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review.
Citation Text:
Cadet T, Cusimano J, McKearney S, et al. Describing the evidence linking interprofessional education interventio…
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psnet.ahrq.gov/issue/does-lean-management-improve-patient-safety-culture-extensive-evaluation-safety-culture
December 05, 2018 - Study
Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.
Citation Text:
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiot…
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psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using
November 16, 2022 - Study
Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.
Citation Text:
Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream infe…
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psnet.ahrq.gov/issue/teamstepps-improving-diagnosis-team-assessment-tool-scale-development-and-psychometric
January 22, 2025 - Study
The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation.
Citation Text:
Ali KJ, Goeschel CA, Eckroade MM, et al. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. Jt Comm J …
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psnet.ahrq.gov/issue/reducing-adverse-drug-events-lessons-breakthrough-series-collaborative
August 04, 2021 - Study
Classic
Reducing adverse drug events: lessons from a breakthrough series collaborative.
Citation Text:
Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. 2000;26(6…
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psnet.ahrq.gov/issue/implementing-standardized-operating-room-briefings-and-debriefings-large-regional-medical
January 03, 2017 - Study
Implementing standardized operating room briefings and debriefings at a large regional medical center.
Citation Text:
Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qua…
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - Promising Areas for Patient Safety Research
December 1, 2003
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003.
https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
Perspective
Setting a Course for Patient Safety Research
Although patient safety…
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - The Role of the Patient in Improving Patient Safety
March 1, 2007
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
Perspective
Patients have three roles in improving patient safety: helping to ensure thei…
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions
Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD
| November 16, 2022
Also Read the Conversation
View more articles from the same aut…
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD
November 16, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/46123/psn-pdf
January 01, 2020 - Improving patient safety in handover from intensive care
unit to general ward: a systematic review.
June 21, 2017
Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A
Systematic Review. J Patient Saf. 2020;16(3):199-210. doi:10.1097/pts.0000000000000266.
https://p…
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psnet.ahrq.gov/node/42656/psn-pdf
April 21, 2015 - Improving quality and safety of care using
"technovigilance": an ethnographic case study of
secondary use of data from an electronic prescribing and
decision support system.
April 21, 2015
Dixon-Woods M, Redwood S, Leslie M, et al. Improving quality and safety of care using "technovigilance":
an ethnographic case…
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psnet.ahrq.gov/node/74236/psn-pdf
January 12, 2022 - Can SBAR be implemented with high fidelity and does it
improve communication between healthcare workers? A
systematic review.
January 12, 2022
Lo L, Rotteau L, Shojania KG. Can SBAR be implemented with high fidelity and does it improve
communication between healthcare workers? A systematic review. BMJ Open. 2021;1…
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psnet.ahrq.gov/node/841759/psn-pdf
December 21, 2022 - Sources of nurse-sensitive inpatient safety improvement.
December 21, 2022
Dynan L, Smith RB. Sources of nurse?sensitive inpatient safety improvement. Health Serv Res.
2022;57(6):1235-1246. doi:10.1111/1475-6773.13979.
https://psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement
Nurses play a …
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psnet.ahrq.gov/node/47013/psn-pdf
April 07, 2019 - An electronic intervention to improve safety for pain
patients co-prescribed chronic opioids and
benzodiazepines.
April 7, 2019
Zaman T, Rife TL, Batki SL, et al. An electronic intervention to improve safety for pain patients co-
prescribed chronic opioids and benzodiazepines. Subst Abus. 2018;39(4):441-448.
doi:…
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - Verifying patient identity and site of surgery: improving
compliance with protocol by audit and feedback.
January 14, 2009
Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance
with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8.
doi:10.11…
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psnet.ahrq.gov/node/44952/psn-pdf
March 02, 2016 - Engaging pediatric resident physicians in quality
improvement through resident-led morbidity and mortality
conferences.
March 2, 2016
Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through
Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/47099/psn-pdf
May 16, 2018 - Defense Health Agency Should Improve Tracking of
Serious Adverse Medical Events and Monitoring of
Required Follow-up.
May 16, 2018
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
https://psnet.ahrq.gov/issue/defense-health-agency-should-improve-tracking-serious-a…