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psnet.ahrq.gov/node/46787/psn-pdf
October 15, 2018 - Institute for Safe Medication Practices International
Mentorship Program.
October 15, 2018
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/institute-safe-medication-practices-international-mentorship-program
Structured interaction with a wide variety of experts and environments enables medica…
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psnet.ahrq.gov/node/837667/psn-pdf
July 13, 2022 - Challenges and opportunities of patient safety event
reporting.
July 13, 2022
Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform.
2022;291:133-150. doi:10.3233/shti220014.
https://psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting
Repor…
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psnet.ahrq.gov/node/74848/psn-pdf
February 16, 2022 - Patients for Patient Safety US.
February 16, 2022
404.510.8787; info@pfps.us
https://psnet.ahrq.gov/issue/patients-patient-safety-us
Patient safety improvement has made progress but more can be done. This organization supports
community efforts in the United States to engage policymakers in work toward aligning ef…
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psnet.ahrq.gov/node/46080/psn-pdf
August 28, 2017 - A growth mindset approach to preparing trainees for
medical error.
August 28, 2017
Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error.
BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416.
https://psnet.ahrq.gov/issue/growth-mindset-approach-preparing…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/50556/psn-pdf
January 01, 2021 - The compliance with a patient safety bundle for
management of placenta accreta spectrum.
October 16, 2019
Quist-Nelson J, Crank A, Oliver EA, et al. The compliance with a patient-safety bundle for management of
placenta accreta spectrum†. J Matern Fetal Neonatal Med. 2021;34(17):2880-2886.
doi:10.1080/14767058.201…
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psnet.ahrq.gov/node/45364/psn-pdf
September 04, 2016 - A piece of my mind. Changing the narrative.
September 4, 2016
Allen-Dicker J. Changing the Narrative. JAMA. 2016;316(3). doi:10.1001/jama.2016.3029.
https://psnet.ahrq.gov/issue/piece-my-mind-changing-narrative
Storytelling can share knowledge and build community among physicians. However, if clinicians
communicat…
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psnet.ahrq.gov/node/46244/psn-pdf
June 28, 2017 - Changing the narratives for patient safety.
June 28, 2017
Pronovost P, Sutcliffe K, Basu L, et al. Changing the narratives for patient safety. Bull World Health Organ.
2017;95(6):478-480. doi:10.2471/BLT.16.178392.
https://psnet.ahrq.gov/issue/changing-narratives-patient-safety
Mental models represent established …
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psnet.ahrq.gov/node/38907/psn-pdf
January 03, 2017 - Applying Toyota Production System principles to a
psychiatric hospital: making transfers safer and more
timely.
January 3, 2017
Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making
transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448.
https…
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psnet.ahrq.gov/node/46401/psn-pdf
September 13, 2017 - Understanding middle managers' influence in
implementing patient safety culture.
September 13, 2017
Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture.
BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4.
https://psnet.ahrq.gov/issue/understanding-mid…
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psnet.ahrq.gov/node/73894/psn-pdf
February 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings
of a Workshop—in Brief.
February 22, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National
Academies Press; 2022.
https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis
Diagnostic errors remain an o…
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psnet.ahrq.gov/node/48067/psn-pdf
June 12, 2019 - Maternal sleepiness and risk of infant drops in the
postpartum period.
June 12, 2019
Bittle MD, Knapp H, Polomano RC, et al. Maternal Sleepiness and Risk of Infant Drops in the Postpartum
Period. Jt Comm J Qual Patient Saf. 2019;45(5):337-347. doi:10.1016/j.jcjq.2018.12.001.
https://psnet.ahrq.gov/issue/maternal-s…
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psnet.ahrq.gov/node/45315/psn-pdf
September 07, 2016 - Healthcare professionals' views on feedback of a patient
safety culture assessment.
September 7, 2016
Zwijnenberg NC, Hendriks M, Hoogervorst-Schilp J, et al. Healthcare professionals' views on feedback of a
patient safety culture assessment. BMC Health Serv Res. 2016;16:199. doi:10.1186/s12913-016-1404-8.
https:/…
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psnet.ahrq.gov/node/44863/psn-pdf
July 01, 2016 - Rating the raters: the inconsistent quality of health care
performance measurement.
July 1, 2016
Shahian DM, Normand S-LT, Friedberg MW, et al. Rating the Raters: The Inconsistent Quality of Health
Care Performance Measurement. Ann Surg. 2016;264(1):36-8. doi:10.1097/SLA.0000000000001631.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47684/psn-pdf
March 20, 2019 - The impact of mobile technology on teamwork and
communication in hospitals: a systematic review.
March 20, 2019
Martin G, Khajuria A, Arora S, et al. The impact of mobile technology on teamwork and communication in
hospitals: a systematic review. J Am Med Inform Assoc. 2019;26(4):339-355. doi:10.1093/jamia/ocy175.
…
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psnet.ahrq.gov/node/40550/psn-pdf
June 22, 2011 - Applying a multidisciplinary approach to the selection,
evaluation, and acquisition of smart infusion pumps.
June 22, 2011
Namshirin P. Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart
infusion pumps. . J Med Bio Eng. 2011;31(2):93-98. doi:10.5405/jmbe.839.
https://psnet…
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psnet.ahrq.gov/node/60008/psn-pdf
July 09, 2024 - IHI Patient Safety Congress.
July 9, 2024
Institute for Healthcare Improvement. San Diego, CA, March 10-11, 2025.
https://psnet.ahrq.gov/issue/ihi-patient-safety-congress
This annual conference will host pre-session workshops, panels, and presentations covering a variety of
patient safety topics that ali…
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psnet.ahrq.gov/node/44300/psn-pdf
July 29, 2015 - Learning From Serious Failings in Care: Main Report.
July 29, 2015
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges
and Faculties in Scotland; May 2015.
https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
Substantive reports of failures have t…
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psnet.ahrq.gov/node/45565/psn-pdf
May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success.
May 24, 2017
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian
Leape Institute; 2017.
https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success
Health care leadership plays an undeniable role in sust…
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psnet.ahrq.gov/node/851461/psn-pdf
July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating
them.
July 19, 2023
Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395.
doi:10.1097/pts.0000000000001140.
https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them
…