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psnet.ahrq.gov/node/865310/psn-pdf
March 27, 2024 - Organizational learning in the morbidity and mortality
conference.
March 27, 2024
Batthish M, Kuper A, Fine C, et al. Organizational learning in the morbidity and mortality conference. J
Healthc Qual. 2024;46(2):100-108. doi:10.1097/jhq.0000000000000416.
https://psnet.ahrq.gov/issue/organizational-learning-morbidi…
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psnet.ahrq.gov/node/838076/psn-pdf
September 14, 2022 - The ‘new view’ of human error. Origins, ambiguities,
successes and critiques.
September 14, 2022
Le Coze JC. The ‘new view’ of human error. Origins, ambiguities, successes and critiques. Safety Sci.
2022;154:105853. doi:10.1016/j.ssci.2022.105853.
https://psnet.ahrq.gov/issue/new-view-human-error-origins-ambiguiti…
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psnet.ahrq.gov/node/47859/psn-pdf
May 15, 2019 - The design and conduct of Project RedDE: a cluster-
randomized trial to reduce diagnostic errors in pediatric
primary care.
May 15, 2019
Bundy DG, Singh H, Stein RE, et al. The design and conduct of Project RedDE: A cluster-randomized trial
to reduce diagnostic errors in pediatric primary care. Clin Trials. 2019;1…
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psnet.ahrq.gov/node/35977/psn-pdf
February 17, 2011 - Making patient safety the centerpiece of medical liability
reform.
February 17, 2011
Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England
Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100.
https://psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical…
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psnet.ahrq.gov/node/73956/psn-pdf
October 13, 2021 - Acute care nurses' perceptions of leadership, teamwork,
turnover intention and patient safety - a mixed methods
study.
October 13, 2021
Zaheer S, Ginsburg LR, Wong HJ, et al. Acute care nurses’ perceptions of leadership, teamwork, turnover
intention and patient safety – a mixed methods study. BMC Nurs. 2021;20(1):…
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psnet.ahrq.gov/node/72609/psn-pdf
December 23, 2020 - Covid-19 surge could lead to another drop in patient
visits, doctors fear—and more missed pediatric cancers.
December 23, 2020
Cooney E. StatNews. December 10, 2020.
https://psnet.ahrq.gov/issue/covid-19-surge-could-lead-another-drop-patient-visits-doctors-fear-and-more-
missed-pediatric
Timely and proactive…
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psnet.ahrq.gov/node/838088/psn-pdf
September 14, 2022 - 'We had such trust, we feel such fools’: how shocking
hospital mistakes led to our daughter’s death.
September 14, 2022
Mills M. The Guardian. September 3, 2022.
https://psnet.ahrq.gov/issue/we-had-such-trust-we-feel-such-fools-how-shocking-hospital-mistakes-led-our-
daughters-death
Families experiencing medical …
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psnet.ahrq.gov/node/34796/psn-pdf
November 18, 2015 - The business case for quality: case studies and an
analysis.
November 18, 2015
Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis.
Health Aff (Millwood). 2003;22(2):17-30.
https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
This comprehens…
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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/node/43660/psn-pdf
November 12, 2014 - Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for Disease
Control and Prevention–convened meeting.
November 12, 2014
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for …
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psnet.ahrq.gov/node/73405/psn-pdf
June 16, 2021 - 2020 Eisenberg Award recipients announced by The Joint
Commission, National Quality Forum.
June 16, 2021
Oakbrook Terrace, IL: Joint Commission: June 8, 2021.
https://psnet.ahrq.gov/issue/2020-eisenberg-award-recipients-announced-joint-commission-national-
quality-forum
The Eisenberg Award honors individuals and …
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psnet.ahrq.gov/node/40446/psn-pdf
July 02, 2014 - Shifting indirect patient care duties to after hours in the
era of work hours restrictions.
July 2, 2014
Mourad M, Vidyarthi A, Hollander H, et al. Shifting indirect patient care duties to after hours in the era of
work hours restrictions. Acad Med. 2011;86(5):586-90. doi:10.1097/ACM.0b013e318212e1cb.
https://psne…
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psnet.ahrq.gov/node/853970/psn-pdf
September 27, 2023 - Clinical triggers and vital signs influencing crisis
acknowledgment and calls for help by anesthesiologists:
a simulation-based observational study.
September 27, 2023
Matern LH, Gardner R, Rudolph JW, et al. Clinical triggers and vital signs influencing crisis
acknowledgment and calls for help by anesthesiologist…
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psnet.ahrq.gov/node/838930/psn-pdf
October 26, 2022 - Artificial Intelligence in Health Care: Benefits and
Challenges of Machine Learning Technologies for Medical
Diagnostics.
October 26, 2022
Washington DC: United States Government Accountability Office and National Academy of
Medicine; September 2022. Report no. GAO-22-104629.
https://psnet.ahrq.gov/issue/ar…
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psnet.ahrq.gov/node/47903/psn-pdf
January 01, 2021 - A qualitative analysis of outpatient medication use in
community settings: observed safety vulnerabilities and
recommendations for improved patient safety.
April 17, 2019
Lyson HC, Sharma AE, Cherian R, et al. A Qualitative Analysis of Outpatient Medication Use in Community
Settings: Observed Safety Vulnerabilitie…
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psnet.ahrq.gov/node/50424/psn-pdf
September 04, 2019 - From box ticking to the black box: the evolution of
operating room safety.
September 4, 2019
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety.
World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
https://psnet.ahrq.gov/issue/box-ticking-black-box-e…
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psnet.ahrq.gov/node/50700/psn-pdf
January 01, 2020 - Developing health care organizations that pursue learning
and exploration of diagnostic excellence: an action plan.
December 4, 2019
Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and
Exploration of Diagnostic Excellence: An Action Plan. Acad Med. 2020;95(8):1172-1178.
…
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psnet.ahrq.gov/node/37610/psn-pdf
June 16, 2011 - Is yours a learning organization?
June 16, 2011
Garvin DA, Edmondson A, Gino F. Is yours a learning organization? Harv Bus Rev. 2008;86(3):109-16,
134.
https://psnet.ahrq.gov/issue/yours-learning-organization
Key tenets of improving patient safety at the organizational level include taking a systems approach to
s…
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psnet.ahrq.gov/node/867077/psn-pdf
November 20, 2023 - Interprofessional Education Collaborative Core
Competencies for Interprofessional Collaborative Practice
November 20, 2023
Interprofessional Education Collaborative Core Competencies For Interprofessional Collaborative Practice.
Washington DC: Interprofessional Education Collaborative; 2023.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/73472/psn-pdf
July 07, 2021 - Safety checklists for emergency response driving and
patient transport: experiences from emergency medical
services.
July 7, 2021
Jakonen A, Mänty M, Nordquist H. Safety checklists for emergency response driving and patient transport:
experiences from emergency medical services. Jt Comm J Qual Patient Saf. 2021;47…