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psnet.ahrq.gov/node/39396/psn-pdf
November 02, 2014 - Unmet Needs: Teaching Physicians to Provide Safe
Patient Care.
November 2, 2014
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
Medical schools face an urgent need to transform their cur…
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psnet.ahrq.gov/node/42154/psn-pdf
January 07, 2015 - Paper- and computer-based workarounds to electronic
health record use at three benchmark institutions.
January 7, 2015
Flanagan ME, Saleem JJ, Millitello LG, et al. Paper- and computer-based workarounds to electronic health
record use at three benchmark institutions. J Am Med Inform Assoc. 2013;20(e1):e59-66.
doi:…
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psnet.ahrq.gov/node/47491/psn-pdf
November 07, 2018 - Integrating patient safety education into early medical
education utilizing cadaver, sponges, and an inter-
professional team.
November 7, 2018
Kutaimy R, Zhang L, Blok D, et al. Integrating patient safety education into early medical education utilizing
cadaver, sponges, and an inter-professional team. BMC Med Ed…
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psnet.ahrq.gov/node/46027/psn-pdf
July 02, 2019 - Dissecting Leapfrog: how well do Leapfrog Safe Practices
Scores correlate with Hospital Compare ratings and
penalties, and how much do they matter?
July 2, 2019
Smith SN, Reichert HA, Ameling JM, et al. Dissecting Leapfrog: How Well Do Leapfrog Safe Practices
Scores Correlate With Hospital Compare Ratings and Pena…
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psnet.ahrq.gov/issue/escape-room
April 30, 2024 - Tools/Toolkit
Escape Room.
Citation Text:
Escape Room. Harrisburg, PA: Pennsylvania Safety Authority; 2020.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/45380/psn-pdf
November 11, 2016 - Innovative patient safety curriculum using iPad game
(PASSED) improved patient safety concepts in
undergraduate medical students.
November 11, 2016
Kow AWC, Ang BLS, Chong CS, et al. Innovative Patient Safety Curriculum Using iPAD Game (PASSED)
Improved Patient Safety Concepts in Undergraduate Medical Students. Wo…
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psnet.ahrq.gov/node/42711/psn-pdf
October 31, 2014 - Characterising the complexity of medication safety using
a human factors approach: an observational study in two
intensive care units.
October 31, 2014
Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a
human factors approach: an observational study in two inten…
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy
Helak about Application of Safety-II Principles
August 28, 2024
In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-an…
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - example, may not need to hire
coaches for staff education if the standardized measures are properly incorporated
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - Documentation review may need to be incorporated into peer review processes in order to heighten the
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - The recommendation for checklists has been echoed by other experts and has been incorporated into the
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psnet.ahrq.gov/issue/residency-evaluations-where-patient-voice
June 21, 2023 - Commentary
Residency evaluations—where is the patient voice?
Citation Text:
Tummalapalli SL. Residency Evaluations-Where Is the Patient Voice? JAMA Intern Med. 2017;177(12):1722-1723. doi:10.1001/jamainternmed.2017.6029.
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DOI Google Scholar PubMed BibTe…
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psnet.ahrq.gov/node/47210/psn-pdf
November 16, 2018 - A multi-stakeholder consensus-driven research agenda
for better understanding and supporting the emotional
impact of harmful events on patients and families.
November 16, 2018
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for
Better Understanding and Supporting the …
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psnet.ahrq.gov/node/836843/psn-pdf
April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated
checklist for clinical decision support during PICU daily
rounds.
April 7, 2022
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist
for clinical decision support during PICU daily rounds. Pediatr Crit Care…
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Oxford University
Press, Incorporated; 1998.
9. Bazemore A, Grunert T. … Oxford, UK:
Oxford University Press, Incorporated; 1998. 448 p.
29.
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psnet.ahrq.gov/issue/patient-safety-17
April 30, 2024 - Newsletter/Journal
Patient Safety.
Citation Text:
Patient Safety. Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - hospital-based substance abuse counselors often provide counseling and resources, they are often not formally incorporated … ED providers. 15 This tool is consistent with fundamentals of patient safety improvement and can be incorporated