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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…
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psnet.ahrq.gov/node/837297/psn-pdf
June 01, 2022 - Checklists to reduce diagnostic error: a systematic review
of the literature using a human factors framework.
June 1, 2022
Al-Khafaji J, Townshend RF, Townsend W, et al. Checklists to reduce diagnostic error: a systematic review
of the literature using a human factors framework. BMJ Open. 2022;12(4):e058219. doi:10…
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psnet.ahrq.gov/node/40326/psn-pdf
May 25, 2011 - The impact of computerized provider order entry systems
on medical-imaging services: a systematic review.
May 25, 2011
Georgiou A, Prgomet M, Markewycz A, et al. The impact of computerized provider order entry systems on
medical-imaging services: a systematic review. J Am Med Inform Assoc. 2011;18(3):335-40.
doi:1…
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psnet.ahrq.gov/node/39338/psn-pdf
April 30, 2014 - The effect of multidisciplinary care teams on intensive
care unit mortality.
April 30, 2014
Kim MM, Barnato AE, Angus DC, et al. The effect of multidisciplinary care teams on intensive care unit
mortality. Arch Intern Med. 2010;170(4):369-76. doi:10.1001/archinternmed.2009.521.
https://psnet.ahrq.gov/issue/effect-…
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psnet.ahrq.gov/node/40309/psn-pdf
April 22, 2011 - The role of theory in research to develop and evaluate the
implementation of patient safety practices.
April 22, 2011
Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the
implementation of patient safety practices. BMJ Qual Saf. 2011;20(5):453-9.
doi:10.1136/bmjqs.2010…
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psnet.ahrq.gov/node/45562/psn-pdf
October 12, 2016 - Characterising the nature of primary care patient safety
incident reports in the England and Wales National
Reporting and Learning System: a mixed-methods
agenda-setting study for general practice.
October 12, 2016
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising The Nature Of Primary Care Patient Sa…
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psnet.ahrq.gov/node/41369/psn-pdf
May 29, 2015 - Cognitive interventions to reduce diagnostic error: a
narrative review.
May 29, 2015
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative
review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjqs-2011-000149.
https://psnet.ahrq.gov/issue/cognitive-interventions-re…
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psnet.ahrq.gov/node/45955/psn-pdf
January 01, 2021 - The essential role of leadership in developing a safety
culture.
April 3, 2017
The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8.
https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
The Joint Commission issues sentinel event alerts t…
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psnet.ahrq.gov/node/40673/psn-pdf
September 03, 2011 - Evaluating efforts to optimize TeamSTEPPS
implementation in surgical and pediatric intensive care
units.
September 3, 2011
Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical
and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365-374.
htt…
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psnet.ahrq.gov/node/43041/psn-pdf
January 06, 2015 - Through the Eyes of the Workforce: Creating Joy,
Meaning, and Safer Health Care.
January 6, 2015
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA:
National Patient Safety Foundation; 2013.
https://psnet.ahrq.gov/issue/through-eyes-workforce-creating-joy-meaning-and…
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psnet.ahrq.gov/node/37114/psn-pdf
October 04, 2011 - A descriptive study of morbidity and mortality
conferences and their conformity to medical incident
analysis models: results of the morbidity and mortality
conference improvement study, phase 1.
October 4, 2011
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of morbidity and mortality conference…
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psnet.ahrq.gov/node/46236/psn-pdf
April 03, 2018 - The impact of a diagnostic decision support system on
the consultation: perceptions of GPs and patients.
April 3, 2018
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the
consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
doi:10.1186/s12…
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psnet.ahrq.gov/node/61110/psn-pdf
November 11, 2020 - Association between parent comfort with English and
adverse events among hospitalized children.
November 11, 2020
Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events
among hospitalized children. JAMA Pediatr. 2020;174(12):e203215.
doi:10.1001/jamapediatrics.2020.3215.…
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psnet.ahrq.gov/node/48085/psn-pdf
June 19, 2019 - A decade of preventing harm.
June 19, 2019
Woeltje KF, Olenski LK, Donatelli M, et al. A Decade of Preventing Harm. Jt Comm J Qual Patient Saf.
2019;45(7):480-486. doi:10.1016/j.jcjq.2019.04.007.
https://psnet.ahrq.gov/issue/decade-preventing-harm
Preventable patient safety problems continue to challenge health ca…
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psnet.ahrq.gov/node/74049/psn-pdf
January 01, 2022 - The critical role of health information technology in the
safe integration of behavioral health and primary care to
improve patient care.
November 10, 2021
Segal M, Giuffrida P, Possanza L, et al. The critical role of health information technology in the safe
integration of behavioral health and primary care to im…
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psnet.ahrq.gov/node/45437/psn-pdf
September 01, 2018 - Decreasing malpractice claims by reducing preventable
perinatal harm.
September 1, 2018
Riley W, Meredith LW, Price R, et al. Decreasing Malpractice Claims by Reducing Preventable Perinatal
Harm. Health Serv Res. 2016;51(suppl 3):2453-2471. doi:10.1111/1475-6773.12551.
https://psnet.ahrq.gov/issue/decreasing-malpr…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…