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psnet.ahrq.gov/issue/defining-and-enhancing-collaboration-between-community-pharmacists-and-primary-care-providers
July 07, 2021 - Review
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
Citation Text:
White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists and primary care providers to improve m…
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psnet.ahrq.gov/issue/resident-and-rn-perceptions-impact-medical-emergency-team-education-and-patient-safety
September 24, 2010 - Study
Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.
Citation Text:
Sarani B, Sonnad SS, Bergey MR, et al. Resident and RN perceptions of the impact of a medical emergency team on education and patien…
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psnet.ahrq.gov/issue/how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods
February 21, 2018 - Study
How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.
Citation Text:
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interve…
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psnet.ahrq.gov/issue/effects-multicentre-teamwork-and-communication-programme-patient-outcomes-results-triad
January 16, 2013 - Study
Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.
Citation Text:
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication programme on patient o…
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psnet.ahrq.gov/issue/patient-feedback-safety-improvement-primary-care-results-feasibility-study
December 02, 2020 - Study
Patient feedback for safety improvement in primary care: results from a feasibility study.
Citation Text:
Hernan AL, Giles SJ, Beks H, et al. Patient feedback for safety improvement in primary care: results from a feasibility study. BMJ Open. 2020;10(6):e037887. doi:10.1136/bmjopen…
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psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure-mode-effect-analysis
December 09, 2020 - Study
High rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses.
Citation Text:
Öhrn A, Ericsson C, Andersson C, et al. High Rate of Implementation of Proposed Actions for Improvement With the Healt…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-within-health-care-systematic-review-past-decade
March 05, 2010 - Review
Classic
Interventions to improve team effectiveness within health care: a systematic review of the past decade.
Citation Text:
Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systemati…
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psnet.ahrq.gov/issue/changing-hospital-organisational-culture-improved-patient-outcomes-developing-and
June 17, 2020 - Study
Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.
Citation Text:
Linnander EL, McNatt Z, Boehmer K, et al. Changing hospital organisational culture for improved patient outcomes: developing a…
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psnet.ahrq.gov/issue/identification-patient-information-corruption-intensive-care-unit-using-scoring-tool-direct
August 04, 2021 - Study
Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
Citation Text:
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit: using a scori…
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psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching-university
November 07, 2018 - Commentary
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.
Citation Text:
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more…
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psnet.ahrq.gov/issue/failure-rescue-and-30-day-hospital-mortality-hospitals-and-without-crew-resource-management
January 26, 2022 - Study
Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management safety training.
Citation Text:
Bacon CT, McCoy TP, Henshaw DS. Failure to rescue and 30‐day in‐hospital mortality in hospitals with and without crew‐resource‐management safety…
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psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
August 08, 2018 - Study
Detecting unapproved abbreviations in the electronic medical record.
Citation Text:
Capraro A, Stack AM, Harper MB, et al. Detecting unapproved abbreviations in the electronic medical record. Jt Comm J Qual Patient Saf. 2012;38(4):178-183. doi:10.1016/s1553-7250(12)38023-9.
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.In Conversation with...James L. Reinertsen, MD. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/node/36092/psn-pdf
March 18, 2010 - Improving the safety of telephone or verbal orders.
March 18, 2010
PA-PSRS Patient Saf Advis. 2006 Jun;3(2):1,3-7.
https://psnet.ahrq.gov/issue/improving-safety-telephone-or-verbal-orders
This article shares several examples of errors made while verbally communicating medication orders and
includes recommendations…
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psnet.ahrq.gov/node/42701/psn-pdf
June 27, 2018 - Improving reliability with root cause analysis.
June 27, 2018
Latino RJ
https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
This article relates how root cause analysis, typically used after an adverse event, can be utilized as a
proactive risk assessment tool to enhance reliability.
https://ps…
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…
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psnet.ahrq.gov/node/35320/psn-pdf
September 14, 2005 - How business intelligence can improve patient safety.
September 14, 2005
Wanless S, McManaway J. Metaphor Analytics. August 30, 2005.
https://psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
This article illustrates how hospitals can use their own administrative and patient data to reduce h…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…