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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
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psnet.ahrq.gov/node/50406/psn-pdf
October 02, 2019 - The co-design, implementation and evaluation of a
serious board game 'PlayDecide patient safety' to educate
junior doctors about patient safety and the importance of
reporting safety concerns
October 2, 2019
Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation and evaluation of a serious board game
'Pl…
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psnet.ahrq.gov/node/74203/psn-pdf
December 22, 2021 - Surgical safety checklist audits may be misleading!
Improving the implementation and adherence of the
surgical safety checklist: a quality improvement project.
December 22, 2021
Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading!
Improving the implementation and adherence…
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psnet.ahrq.gov/node/43735/psn-pdf
January 20, 2015 - Patient safety is not elective: a debate at the NPSF Patient
Safety Congress.
January 20, 2015
McTiernan P, Wachter R, Meyer GS, et al. Patient safety is not elective: a debate at the NPSF Patient
Safety Congress. BMJ Qual Saf. 2015;24(2):162-6. doi:10.1136/bmjqs-2014-003429.
https://psnet.ahrq.gov/issue/patient-s…
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psnet.ahrq.gov/node/44061/psn-pdf
November 16, 2015 - Quality improvement and patient safety organizations in
anesthesiology.
November 16, 2015
Dutton RP. Quality improvement and patient safety organizations in anesthesiology. AMA J Ethics.
2015;17(3):248-52. doi:10.1001/journalofethics.2015.17.3.pfor1-1503.
https://psnet.ahrq.gov/issue/quality-improvement-and-patien…
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psnet.ahrq.gov/node/47232/psn-pdf
November 14, 2018 - Managing alarm systems for quality and safety in the
hospital setting.
November 14, 2018
Bach TA, Berglund L-M, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ
Open Qual. 2018;7(3):e000202. doi:10.1136/bmjoq-2017-000202.
https://psnet.ahrq.gov/issue/managing-alarm-systems-quality…
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psnet.ahrq.gov/node/39102/psn-pdf
January 04, 2010 - Quality and safety on an acute surgical ward: an
exploratory cohort study of process and outcome.
January 4, 2010
Kreckler S, Catchpole K, New SJ, et al. Quality and safety on an acute surgical ward: an exploratory cohort
study of process and outcome. Ann Surg. 2009;250(6):1035-40. doi:10.1097/SLA.0b013e3181bd54c2.…
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psnet.ahrq.gov/node/43058/psn-pdf
March 26, 2014 - A strategic approach to quality improvement and patient
safety education and resident integration in a general
surgery residency.
March 26, 2014
O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and
resident integration in a general surgery residency. J Surg Educ. 2014…
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psnet.ahrq.gov/node/867335/psn-pdf
December 11, 2024 - Comparing safety, performance and user perceptions of a
patient-specific indication-based prescribing tool with
current practice: a mixed methods randomised user
testing study.
December 11, 2024
Feather C, Clarke J, Appelbaum N, et al. Comparing safety, performance and user perceptions of a patient-
specific indi…
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psnet.ahrq.gov/node/47158/psn-pdf
August 15, 2018 - A standardized handoff simulation promotes recovery
from auditory distractions in resident physicians.
August 15, 2018
Matern LH, Farnan JM, Hirsch KW, et al. A Standardized Handoff Simulation Promotes Recovery From
Auditory Distractions in Resident Physicians. Simul Healthc. 2018;13(4):233-238.
doi:10.1097/SIH.00…
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psnet.ahrq.gov/node/46626/psn-pdf
December 22, 2018 - What happened to my patient? An educational
intervention to facilitate postdischarge patient follow-up.
December 22, 2018
Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to
Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…
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psnet.ahrq.gov/node/43021/psn-pdf
November 04, 2014 - Patient safety culture transformation in a children's
hospital: an interprofessional approach.
November 4, 2014
Nagelkerk J, Peterson T, Pawl BL, et al. Patient safety culture transformation in a children's hospital: an
interprofessional approach. J Interprof Care. 2014;28(4):358-64. doi:10.3109/13561820.2014.88593…
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psnet.ahrq.gov/node/46364/psn-pdf
September 24, 2017 - Exploring the potential for using drug indications to
prevent look-alike and sound-alike drug errors.
September 24, 2017
Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug
indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf. 2017;16(10):…
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psnet.ahrq.gov/node/43210/psn-pdf
May 28, 2014 - Improving cancer patient care with combined medication
error reviews and morbidity and mortality conferences.
May 28, 2014
Ranchon F, You B, Salles G, et al. Improving Cancer Patient Care with Combined Medication Error
Reviews and Morbidity and Mortality Conferences. Chemotherapy (Los Angel). 2014;59(5).
doi:10.11…
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psnet.ahrq.gov/node/44869/psn-pdf
November 18, 2016 - Fake and expired medications in simulation-based
education: an underappreciated risk to patient safety.
November 18, 2016
Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an
underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/47106/psn-pdf
August 15, 2018 - Imitating incidents: how simulation can improve safety
investigation and learning from adverse events.
August 15, 2018
Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From
Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097/SIH.0000000000000315.
https://psnet.…
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psnet.ahrq.gov/node/73140/psn-pdf
April 14, 2021 - Association between primary care physician diagnostic
knowledge and death, hospitalisation and emergency
department visits following an outpatient visit at risk for
diagnostic error: a retrospective cohort study using
medicare claims.
April 14, 2021
Gray BM, Vandergrift JL, McCoy RG, et al. Association between pr…
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psnet.ahrq.gov/node/44459/psn-pdf
October 06, 2016 - Examining the Relationship Between Health IT and
Ambulatory Care Workflow Redesign.
October 6, 2016
Zheng K, Ciemins EL, Lanham HJ, et al. Rockville, MD: Agency for Healthcare Research and Quality; July
2015. AHRQ Publication No. 15-0058-EF.
https://psnet.ahrq.gov/issue/examining-relationship-between-health-it-and…
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psnet.ahrq.gov/node/34649/psn-pdf
June 11, 2014 - On error management: lessons from aviation.
June 11, 2014
Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785.
https://psnet.ahrq.gov/issue/error-management-lessons-aviation
In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and
…
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psnet.ahrq.gov/node/38400/psn-pdf
February 11, 2009 - The impact of clinically undiagnosed injuries on survival
estimates.
February 11, 2009
Gedeborg R, Thiblin I, Byberg L, et al. The impact of clinically undiagnosed injuries on survival estimates.
Crit Care Med. 2009;37(2). doi:10.1097/ccm.0b013e318194b164.
https://psnet.ahrq.gov/issue/impact-clinically-undiagnosed…