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psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
March 10, 2021 - Review
Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.
Citation Text:
Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
March 29, 2023 - Review
Classic
Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies.
Citation Text:
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…
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psnet.ahrq.gov/issue/impact-electronic-alert-notification-system-embedded-radiologists-workflow-closed-loop
November 26, 2014 - Study
Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.
Citation Text:
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiolo…
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psnet.ahrq.gov/issue/feasibility-and-added-value-executive-walkrounds-long-term-care-organizations-netherlands
January 07, 2015 - Study
Feasibility and added value of Executive WalkRounds in long term care organizations in the Netherlands.
Citation Text:
van Dusseldorp L, de Waal GH-, Hamers H, et al. Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands. Jt Comm J Q…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/node/60060/psn-pdf
March 18, 2020 - The benefits and burdens of working with patient safety
organizations under the Patient Safety and Quality
Improvement Act of 2005.
March 18, 2020
Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the
Patient Safety and Quality Improvement Act of 2005. J Health Life Sc…
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psnet.ahrq.gov/node/46577/psn-pdf
April 03, 2018 - The new diagnostic team.
April 3, 2018
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238.
doi:10.1515/dx-2017-0022.
https://psnet.ahrq.gov/issue/new-diagnostic-team
Teamwork has been highlighted as a key component of patient safety that also applies to improving
diag…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/47431/psn-pdf
September 26, 2018 - Partnering with pediatric patients and families in high
reliability to identify and reduce preventable safety
events.
September 26, 2018
Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90.
https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-
pr…
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psnet.ahrq.gov/node/50910/psn-pdf
February 19, 2020 - SEIPS 3.0: human-centered design of the patient journey
for patient safety.
February 19, 2020
Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey
for patient safety. App Ergon. 2020;84:103033. doi:10.1016/j.apergo.2019.103033.
https://psnet.ahrq.gov/issue/seips-30-…
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psnet.ahrq.gov/node/44867/psn-pdf
March 23, 2016 - Understanding why quality initiatives succeed or fail: a
sociotechnical systems perspective.
March 23, 2016
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems
Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
https://psnet.ahrq.gov/issue/understand…
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psnet.ahrq.gov/node/837910/psn-pdf
August 24, 2022 - How Safe is Your Care? Measurement and Monitoring of
Safety Through the Eyes of Patients and Their Care
Partners.
August 24, 2022
Jefs L, Kuluski K, MacLaurin A, et al. Ottawa, Ontario, Canada: Healthcare Excellence Canada; 2022.
https://psnet.ahrq.gov/issue/how-safe-your-care-measurement-and-monitoring-safety-thr…
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psnet.ahrq.gov/node/43283/psn-pdf
June 25, 2014 - Development, implementation, and dissemination of the I-
PASS Handoff Curriculum: a multisite educational
intervention to improve patient handoffs.
June 25, 2014
Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I-
PASS handoff curriculum: A multisite educational in…
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psnet.ahrq.gov/node/60823/psn-pdf
August 19, 2020 - Disaster ergonomics: human factors in COVID-19
pandemic emergency management.
August 19, 2020
Sasangohar F, Moats J, Mehta R, et al. Disaster ergonomics: human factors in COVID-19 pandemic
emergency management. Hum Factors. 2020;62(7):1061-1068. doi:10.1177/0018720820939428.
https://psnet.ahrq.gov/issue/disaster-e…
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psnet.ahrq.gov/node/73532/psn-pdf
July 28, 2021 - The standardisation of handoffs in a large academic
paediatric emergency department using I-PASS.
July 28, 2021
Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric
emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e001254. doi:10.1136/bmjoq-2020-
001254.…
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psnet.ahrq.gov/node/46227/psn-pdf
October 30, 2017 - Patient engagement with surgical site infection
prevention: an expert panel perspective.
October 30, 2017
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an
expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3.
…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/45935/psn-pdf
September 29, 2017 - Radiology research in quality and safety: current trends
and future needs.
September 29, 2017
Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and
Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021.
https://psnet.ahrq.gov/issue/radiolog…
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psnet.ahrq.gov/node/72501/psn-pdf
November 25, 2020 - Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses.
November 25, 2020
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses. J Clin Nurs. 2020;29(21-22):4180-4193.
doi:10.111…