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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/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/46651/psn-pdf
January 17, 2018 - Piloting a patient safety and quality improvement co-
curriculum.
January 17, 2018
Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co-
curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357.
doi:10.1080/20009666.2017.1403830.
https://psnet.ahrq.gov/issue/…
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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/38831/psn-pdf
August 05, 2009 - Rural hospital information technology implementation for
safety and quality improvement: lessons learned.
August 5, 2009
Tietze MF, Williams J, Galimbertti M. Rural hospital information technology implementation for safety and
quality improvement: lessons learned. Comput Inform Nurs. 2009;27(4):206-14.
doi:10.1097…
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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/44368/psn-pdf
September 29, 2017 - A systematic review of the effect of distraction on
surgeon performance: directions for operating room
policy and surgical training.
September 29, 2017
Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon
performance: directions for operating room policy and surgical …
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psnet.ahrq.gov/node/45571/psn-pdf
January 18, 2017 - How communication among members of the health care
team affects maternal morbidity and mortality.
January 18, 2017
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects
Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884.
doi:10.1016/j.jogn.2016.03…
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psnet.ahrq.gov/node/44156/psn-pdf
November 10, 2015 - Exploring the role of communications in quality
improvement: a case study of the 1000 Lives Campaign in
NHS Wales.
November 10, 2015
Cooper A, Gray J, Willson A, et al. Exploring the role of communications in quality improvement: A case
study of the 1000 Lives Campaign in NHS Wales. J Commun Healthc. 2015;8(1):76-…
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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/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/866395/psn-pdf
July 23, 2024 - Creating an
environment where a culture of safety is incorporated into daily practice is the ultimate
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - implementation of NPSGs is enhanced through proactive, coordinated, and systems-level approaches that are incorporated
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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/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
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January 17, 2012
A handbook developed by the …