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psnet.ahrq.gov/node/36185/psn-pdf
March 28, 2011 - Defining the technical skills of teamwork in surgery.
March 28, 2011
Healey A, Undre S, Vincent C. Defining the technical skills of teamwork in surgery. Qual Saf Health Care.
2006;15(4):231-4.
https://psnet.ahrq.gov/issue/defining-technical-skills-teamwork-surgery
The authors discuss a strategy for incorporating t…
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psnet.ahrq.gov/node/40003/psn-pdf
November 02, 2012 - Meeting the Joint Commission's 2013 National Patient
Safety Goals.
November 2, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
https://psnet.ahrq.gov/issue/meeting-joint-commissions-2013-national-patient-safety-goals
This e-book provides tips for incorporating activitie…
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - FMEA specifically concerns itself with attempting to anticipate unintended consequences and should be incorporated … the problem of unintended consequences; underutilized because unintended consequences are not always incorporated
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - FMEA specifically concerns itself with attempting to anticipate unintended consequences and should be
incorporated … the problem of unintended consequences; underutilized because unintended
consequences are not always incorporated
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psnet.ahrq.gov/node/45550/psn-pdf
August 01, 2023 - Leape Ahead Award.
August 1, 2023
American Association for Physician Leadership.
https://psnet.ahrq.gov/issue/leape-ahead-award
Efforts to incorporate respect and patient safety concepts into medical training have been inspired by the
work and leadership of Dr. Lucian Leape, founding chairman of the Lucian Leape I…
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psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors
October 03, 2011 - Study
Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.
Citation Text:
Szeinbach S, Seoane-Vazquez E, Parekh A, et al. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203-9.…
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psnet.ahrq.gov/node/33939/psn-pdf
January 17, 2012 - VHA National Patient Safety Improvement Handbook.
January 17, 2012
https://psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
A handbook developed by the VA and the National Center for Patient Safety that provides guidance on how
to limit opportunities that adversely impact patient safety and car…
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psnet.ahrq.gov/node/37383/psn-pdf
March 28, 2012 - Integrating simulation in surgery as a teaching tool and
credentialing standard.
March 28, 2012
Rehrig ST, Powers K, Jones DB. Integrating simulation in surgery as a teaching tool and credentialing
standard. J Gastrointest Surg. 2008;12(2):222-33.
https://psnet.ahrq.gov/issue/integrating-simulation-surgery-teachin…
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psnet.ahrq.gov/node/50784/psn-pdf
January 08, 2020 - Improving Quality of Care and Patient Outcomes During
Care Transitions (R01).
January 8, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01
Communication during patient tra…
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psnet.ahrq.gov/node/854992/psn-pdf
November 01, 2023 - Failure to rescue as a patient safety indicator for
neurosurgical patients: are we there yet?
November 1, 2023
Roy JM, Rumalla K, Skandalakis GP, et al. Failure to rescue as a patient safety indicator for neurosurgical
patients: are we there yet? A systematic review. Neurosurg Rev. 2023;46(1):227. doi:10.1007/s1014…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/39646/psn-pdf
June 30, 2010 - Patient safety: examining the adequacy of the 5 rights of
medication administration.
June 30, 2010
Macdonald M. Patient safety: examining the adequacy of the 5 rights of medication administration. Clin
Nurse Spec. 2010;24(4):196-201. doi:10.1097/NUR.0b013e3181e3605f.
https://psnet.ahrq.gov/issue/patient-safety-exa…
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psnet.ahrq.gov/node/37641/psn-pdf
March 10, 2011 - EHR safety: the way forward to safe and effective
systems.
March 10, 2011
Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am
Med Inform Assoc. 2008;15(3):272-7. doi:10.1197/jamia.M2618.
https://psnet.ahrq.gov/issue/ehr-safety-way-forward-safe-and-effective-syste…
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Within Fairview, we have incorporated just culture into our performance improvement initiatives, such
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psnet.ahrq.gov/node/74703/psn-pdf
January 26, 2022 - Research to improve diagnosis: time to study the real
world.
January 26, 2022
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf.
2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
Diagnostic …
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psnet.ahrq.gov/node/60796/psn-pdf
August 12, 2020 - The challenges and opportunities for shared decision
making highlighted by COVID-19.
August 12, 2020
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making
highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480.e1.
doi:10.1016/j.jaip.2020.07.003.
…
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psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/48093/psn-pdf
July 24, 2019 - Failure to report poor care as a breach of moral and
professional expectation.
July 24, 2019
Ion R, Olivier S, Darbyshire P. Failure to report poor care as a breach of moral and professional
expectation. Nurs Inq. 2019;26(3):e12299. doi:10.1111/nin.12299.
https://psnet.ahrq.gov/issue/failure-report-poor-care-breac…
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psnet.ahrq.gov/node/866645/psn-pdf
September 04, 2024 - Technology-related safety event analysis in community
clinical informatics: a case study.
September 4, 2024
Recsky C, Stowe M, Rush KL, et al. Technology-related safety event analysis in community clinical
informatics: a case study. Stud Health Technol Inform. 2024;315:452-457. doi:10.3233/shti240189.
https://psne…
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psnet.ahrq.gov/issue/using-machine-learning-system-identify-and-prevent-medication-prescribing-errors-clinical-and
June 05, 2018 - Study
Emerging Classic
Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation.
Citation Text:
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Using a machine learning system to identify an…