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psnet.ahrq.gov/node/40871/psn-pdf
October 26, 2011 - Rethinking resident supervision to improve safety: from
hierarchical to interprofessional models.
October 26, 2011
Tamuz M, Giardina TD, Thomas EJ, et al. Rethinking resident supervision to improve safety: From
hierarchical to interprofessional models. J Hosp Med. 2011;6(8):445-452. doi:10.1002/jhm.919.
https://ps…
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psnet.ahrq.gov/node/45730/psn-pdf
December 14, 2016 - Identification of priorities for improvement of medication
safety in primary care: a PRIORITIZE study.
December 14, 2016
Car LT, Papachristou N, Gallagher J, et al. Identification of priorities for improvement of medication safety
in primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17(1):160.
https://psnet.ah…
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psnet.ahrq.gov/node/42788/psn-pdf
January 19, 2014 - Demonstrating high reliability on accountability measures
at The Johns Hopkins Hospital.
January 19, 2014
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39528/psn-pdf
May 19, 2010 - Multidisciplinary team training in a simulation setting for
acute obstetric emergencies: a systematic review.
May 19, 2010
Merién AER, van de Ven J, Mol BW, et al. Multidisciplinary Team Training in a Simulation Setting for Acute
Obstetric Emergencies. Obstetrics & Gynecology. 2010;115(5). doi:10.1097/aog.0b013e318…
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psnet.ahrq.gov/node/39016/psn-pdf
April 04, 2011 - Variation in hospital mortality associated with inpatient
surgery.
April 4, 2011
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N
Engl J Med. 2009;361(14):1368-75. doi:10.1056/NEJMsa0903048.
https://psnet.ahrq.gov/issue/variation-hospital-mortality-associate…
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psnet.ahrq.gov/node/854986/psn-pdf
November 01, 2023 - Implementing a safer and more reliable system to monitor
test results at a teaching university-affiliated facility in a
family medicine group: a quality improvement process
report.
November 1, 2023
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more reliable system to
monitor test re…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/867701/psn-pdf
August 01, 2017 - Toolkit To Improve Safety for Mechanically Ventilated
Patients.
August 1, 2017
Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated
Patients. August 2017.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
Patients requiring mechanica…
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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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psnet.ahrq.gov/node/73677/psn-pdf
September 08, 2021 - Toolkit for Engaging Patients to Improve Diagnostic
Safety.
September 8, 2021
Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No.
21-0047-2-EF.
https://psnet.ahrq.gov/issue/toolkit-engaging-patients-improve-diagnostic-safety
Patient and family engagement is core to ef…
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psnet.ahrq.gov/node/44919/psn-pdf
March 30, 2016 - Rapid response teams improve outcomes—Part 1, Part 2,
and Part 3.
March 30, 2016
Intensive Care Med. 2016;42(4):591-601.
https://psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3
This three-part commentary presents differing views on whether rapid response teams (RRTs) improve
pa…
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psnet.ahrq.gov/node/74114/psn-pdf
November 24, 2021 - Addressing health care disparities by improving quality
and safety.
November 24, 2021
Sentinel Event Alert. Nov 10 2021;(64):1-7.
https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety
Health care disparities are emerging as a core patient safety issue. This alert introduces s…
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psnet.ahrq.gov/node/43372/psn-pdf
April 13, 2016 - A case for improving measurement of intraoperative
iatrogenic injuries.
April 13, 2016
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries.
JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/837593/psn-pdf
June 29, 2022 - Adverse event reporting priorities: an integrative review.
June 29, 2022
Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J
Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945.
https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
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psnet.ahrq.gov/node/42161/psn-pdf
April 03, 2013 - Positioning continuing education: boundaries and
intersections between the domains continuing education,
knowledge translation, patient safety and quality
improvement.
April 3, 2013
Kitto S, Bell M, Peller J, et al. Positioning continuing education: boundaries and intersections between the
domains continuing educ…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/45642/psn-pdf
November 09, 2016 - Rethinking medical ward quality.
November 9, 2016
Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417.
doi:10.1136/bmj.i5417.
https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality
Patient safety research and commentary often focus on specialized care processes rathe…
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psnet.ahrq.gov/node/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…