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psnet.ahrq.gov/node/851458/psn-pdf
July 19, 2023 - Improving handoffs in the perioperative environment: a
conceptual framework of key theories, system factors,
methods, and core interventions to ensure success.
July 19, 2023
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a
conceptual framework of key theories, syste…
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psnet.ahrq.gov/node/47368/psn-pdf
September 12, 2018 - Using co-design to develop a collective leadership
intervention for healthcare teams to improve safety
culture.
September 12, 2018
Ward ME, De Brún A, Beirne D, et al. Using Co-Design to Develop a Collective Leadership Intervention for
Healthcare Teams to Improve Safety Culture. Int J Environ Res Public Health. 20…
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psnet.ahrq.gov/node/849121/psn-pdf
May 17, 2023 - Thematic reviews of patient safety incidents as a tool for
systems thinking: a quality improvement report.
May 17, 2023
Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality
improvement report. BMJ Open Qual. 2023;12(2):e002020. doi:10.1136/bmjoq-2022-002020.
https://psne…
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psnet.ahrq.gov/node/44350/psn-pdf
July 29, 2015 - Reporting and using near-miss events to improve patient
safety in diverse primary care practices: a collaborative
approach to learning from our mistakes.
July 29, 2015
Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in
Diverse Primary Care Practices: A Collaborat…
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psnet.ahrq.gov/node/854374/psn-pdf
October 11, 2023 - Learning from latent safety threats identified during
simulation to improve patient safety.
October 11, 2023
Congenie K, Bartjen L, Gutierrez D, et al. Learning from latent safety threats identified during simulation to
improve patient safety. Jt Comm J Qual Patient Saf. 2023;49(12):716-723. doi:10.1016/j.jcjq.2023…
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psnet.ahrq.gov/node/40216/psn-pdf
February 16, 2011 - Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and length of
stay: retrospective comparative analysis.
February 16, 2011
Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality
improvement initiative on hospital mortalit…
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psnet.ahrq.gov/node/43362/psn-pdf
November 23, 2014 - A systematic review of teamwork in the intensive care
unit: what do we know about teamwork, team tasks, and
improvement strategies?
November 23, 2014
Dietz AS, Pronovost P, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care
unit: what do we know about teamwork, team tasks, and improveme…
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psnet.ahrq.gov/issue/interview-donald-berwick
August 04, 2021 - Commentary
An interview with Donald Berwick.
Citation Text:
Berwick DM. An interview with Donald Berwick. Interview by Paul M Schyve. Jt Comm J Qual Patient Saf. 2006;32(12):661-666.
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psnet.ahrq.gov/issue/2024-ihi-forum
November 28, 2012 - United States Meeting/Conference
2024 IHI Forum
Citation Text:
2024 IHI Forum Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.
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psnet.ahrq.gov/issue/wake-safe
April 22, 2020 - Multi-use Website
Wake Up Safe.
Citation Text:
Wake Up Safe. Society for Pediatric Anesthesia.
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July 16, 2014…
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psnet.ahrq.gov/issue/patients-toolkit-diagnosis
November 08, 2017 - Toolkit
Patient's Toolkit for Diagnosis.
Citation Text:
Patient's Toolkit for Diagnosis. SIDM Patient Engagement Committee. Evanston, IL: Society to Improve Diagnosis in Medicine; October 2018.
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psnet.ahrq.gov/issue/using-workforce-practices-drive-quality-improvement-guide-hospitals
March 22, 2017 - Book/Report
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals.
Citation Text:
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals. McHugh M, Garman A, McAlearney A, Song P, Harrison M. Chicago, IL: Health Research & Educational Tr…
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psnet.ahrq.gov/issue/transforming-hospitals-designing-safety-and-quality
May 01, 2015 - Audiovisual
Transforming Hospitals: Designing for Safety and Quality.
Citation Text:
Transforming Hospitals: Designing for Safety and Quality. Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
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psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system
January 10, 2018 - Special or Theme Issue
Systematically Identified Failure Is the Route to a Successful Health System.
Citation Text:
Systematically Identified Failure Is the Route to a Successful Health System. Tepper J, Martin D, eds. Healthc Pap. 2015;15(2):4-61.
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psnet.ahrq.gov/issue/ihi-patient-safety-congress
February 08, 2011 - United States Meeting/Conference
IHI Patient Safety Congress.
Citation Text:
IHI Patient Safety Congress. Institute for Healthcare Improvement. San Diego, CA, March 10-11, 2025.
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psnet.ahrq.gov/issue/resident-led-institutional-patient-safety-and-quality-improvement-process
November 16, 2022 - Study
A resident-led institutional patient safety and quality improvement process.
Citation Text:
Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. Am J Med Qual. 2012;27(5):369-76. doi:10.1177/1062860611429387.
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psnet.ahrq.gov/issue/eight-recommendations-policies-communicating-abnormal-test-results
March 10, 2011 - Commentary
Eight recommendations for policies for communicating abnormal test results.
Citation Text:
Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf. 2010;36(5):226-232.
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psnet.ahrq.gov/issue/infusion-medication-error-reduction-two-person-verification-quality-improvement-initiative
June 19, 2019 - Commentary
Infusion medication error reduction by two-person verification: a quality improvement initiative.
Citation Text:
Subramanyam R, Mahmoud M, Buck D, et al. Infusion Medication Error Reduction by Two-Person Verification: A Quality Improvement Initiative. Pediatrics. 2016;138(6). …
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psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-accountability
July 11, 2018 - Book/Report
Actions Needed to Address Employee Misconduct Process and Ensure Accountability.
Citation Text:
Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137. …
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psnet.ahrq.gov/issue/implementing-team-based-daily-goals-sheet-non-icu-setting
January 03, 2017 - Commentary
Implementing a team-based daily goals sheet in a non-ICU setting.
Citation Text:
Holzmueller CG, Timmel J, Kent P, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8, 341.
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