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psnet.ahrq.gov/node/72515/psn-pdf
January 15, 2025 - AHRQ’s Surveys on Patient Safety Culture® Program: An
Overview for New Users.
December 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025.
https://psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool
An organization’s understanding of its culture is foundational t…
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psnet.ahrq.gov/node/47712/psn-pdf
February 20, 2019 - A cognitive forcing tool to mitigate cognitive bias—a
randomised control trial.
February 20, 2019
O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial.
BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3.
https://psnet.ahrq.gov/issue/cognitive-forcing…
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psnet.ahrq.gov/node/837346/psn-pdf
June 08, 2022 - Decontamination of Surgical Instruments.
June 8, 2022
Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.
https://psnet.ahrq.gov/issue/decontamination-surgical-instruments
Surgical equipment sterilization can be hampered by equipment design, production pressures, process
complexity and policy mi…
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psnet.ahrq.gov/node/44023/psn-pdf
November 16, 2015 - Impact of organizations on healthcare-associated
infections.
November 16, 2015
Castro-Sánchez E, Holmes AH. Impact of organizations on healthcare-associated infections. J Hosp Infect.
2015;89(4):346-50. doi:10.1016/j.jhin.2015.01.012.
https://psnet.ahrq.gov/issue/impact-organizations-healthcare-associated-infectio…
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psnet.ahrq.gov/node/45363/psn-pdf
September 14, 2016 - Effective perioperative communication to enhance patient
care.
September 14, 2016
Garrett H. Effective Perioperative Communication to Enhance Patient Care. AORN J. 2016;104(2):111-20.
doi:10.1016/j.aorn.2016.06.001.
https://psnet.ahrq.gov/issue/effective-perioperative-communication-enhance-patient-care
Poor team …
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psnet.ahrq.gov/node/44442/psn-pdf
August 26, 2015 - How your hospital can make you sick.
August 26, 2015
Consumer Reports. July 29, 2015.
https://psnet.ahrq.gov/issue/how-your-hospital-can-make-you-sick
This news article reports on health care–associated infections, particularly Clostridium difficile and
methicillin-resistant Staphylococcus aureus, discusses ways h…
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psnet.ahrq.gov/node/73359/psn-pdf
June 02, 2020 - Patient Safety Movement Foundation.
June 2, 2020
15642 Sand Canyon Ave. #51268, Irvine, CA 92619. 877-236-0279, info@psmf.org.
https://psnet.ahrq.gov/issue/patient-safety-movement-foundation
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the
…
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psnet.ahrq.gov/node/46059/psn-pdf
July 11, 2017 - Pathologists' perspectives on disclosing harmful
pathology error.
July 11, 2017
Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology
Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA.
https://psnet.ahrq.gov/issue/pathologists-perspectives…
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psnet.ahrq.gov/node/45951/psn-pdf
October 31, 2017 - A systematic review of team training in health care: ten
questions.
October 31, 2017
Marlow SL, Hughes A, Sonesh SC, et al. A Systematic Review of Team Training in Health Care: Ten
Questions. Jt Comm J Qual Patient Saf. 2017;43(4):197-204. doi:10.1016/j.jcjq.2016.12.004.
https://psnet.ahrq.gov/issue/systematic-rev…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/73861/psn-pdf
September 22, 2021 - Bringing the clinical laboratory into the strategy to
advance diagnostic excellence.
September 22, 2021
Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance
diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43050/psn-pdf
March 19, 2014 - Electronic Health Record Programs: Participation Has
Increased, but Action Needed to Achieve Goals, Including
Improved Quality of Care.
March 19, 2014
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-
207.
https://psnet.ahrq.gov/issue/electronic-health-record-progr…
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psnet.ahrq.gov/node/863764/psn-pdf
March 06, 2024 - Medication errors 2023: the year in review: January
through December.
March 6, 2024
Pharmacy Practice News; February 2024: Suppl 1-12.
https://psnet.ahrq.gov/issue/medication-errors-2023-year-review-january-through-december
The medication process has multiple steps in it that can open the door to mistakes. This ar…
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psnet.ahrq.gov/node/40130/psn-pdf
January 12, 2011 - Patient safety culture: factors that influence clinician
involvement in patient safety behaviours.
January 12, 2011
Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician
involvement in patient safety behaviours. Qual Saf Health Care. 2010;19(6):585-91.
doi:10.1136/qshc…
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psnet.ahrq.gov/node/47268/psn-pdf
May 11, 2019 - Measuring shared mental models in healthcare.
May 11, 2019
Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219.
https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare
Shared mental models are an important element of team collaboration. This review explores the current…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/37895/psn-pdf
July 09, 2008 - Accidents, claiming, and regional subcultures: are
medical errors and malpractice lawsuits related to social
capital?
July 9, 2008
Williams J. Accidents, claiming, and regional subcultures: Are medical errors and malpractice lawsuits
related to social capital? J Safety Res. 2008;39(3). doi:10.1016/j.jsr.2008.01.00…
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psnet.ahrq.gov/node/44546/psn-pdf
December 14, 2016 - Diagnostic delays in paediatric stroke.
December 14, 2016
Mallick AA, Ganesan V, Kirkham FJ, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg
Psychiatry. 2015;86(8):917-21. doi:10.1136/jnnp-2014-309188.
https://psnet.ahrq.gov/issue/diagnostic-delays-paediatric-stroke
Diagnostic error is a rapidly …
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psnet.ahrq.gov/node/74100/psn-pdf
November 24, 2021 - Pediatric medication errors and reduction strategies in
the perioperative period.
November 24, 2021
Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
https://psnet.ahrq.gov/issue/pediatric-medication-errors-and-reduction-strategies-perioperative-period
Pediatric medication errors during anesthesia …
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psnet.ahrq.gov/node/38200/psn-pdf
November 05, 2008 - Measuring mobile patient safety information system
success: an empirical study.
November 5, 2008
Jen W-Y, Chao C-C. Measuring mobile patient safety information system success: an empirical study. Int J
Med Inform. 2008;77(10):689-97. doi:10.1016/j.ijmedinf.2008.03.003.
https://psnet.ahrq.gov/issue/measuring-mobile…