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psnet.ahrq.gov/node/47053/psn-pdf
May 23, 2018 - TeamSTEPPS Canada.
May 23, 2018
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/teamstepps-canada
The TeamSTEPPS program was developed to support effective communication and teamwork skills in
various health care settings. This site supports the Canadian TeamSTEPPS initiative. The program will
pre…
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psnet.ahrq.gov/node/37247/psn-pdf
December 15, 2011 - Perinatal clinical decision support system: a
documentation tool for patient safety.
December 15, 2011
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs
Womens Health. 2007;11(4):407-10.
https://psnet.ahrq.gov/issue/perinatal-clinical-decision-support-syst…
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - In 2018, institutional priorities at the University of Kansas Hospital
shifted and the team transitioned
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psnet.ahrq.gov/node/47262/psn-pdf
August 22, 2018 - The Case for Medication Safety Officers (MSO).
August 22, 2018
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso
Medication safety is a concern in various settings across an organization. This white paper discusses the
role of a medication …
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psnet.ahrq.gov/node/43897/psn-pdf
August 21, 2015 - Guidelines for Adult IV Push Medications.
August 21, 2015
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
https://psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects
applied expert…
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psnet.ahrq.gov/node/74069/psn-pdf
September 20, 2022 - Diagnostic Excellence.
September 20, 2022
JAMA. Nov 2021-Sep 2022.
https://psnet.ahrq.gov/issue/diagnostic-excellence-0
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series
covers diagnosis as it relates to the Institute of Medicine quality domains, clinical ch…
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psnet.ahrq.gov/node/36778/psn-pdf
August 26, 2011 - What medications does your patient take? Enhancing
medication safety in the outpatient setting.
August 26, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-
outpatient-setting
This article discusses the importance of me…
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psnet.ahrq.gov/node/39778/psn-pdf
August 18, 2010 - Eight-year experience with a neurosurgical checklist.
August 18, 2010
Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8.
doi:10.1177/1062860610363305.
https://psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
A 6-item checklist was successfully impleme…
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psnet.ahrq.gov/node/841489/psn-pdf
December 14, 2022 - Rise to Health Coalition.
December 14, 2022
Boston, MA; Institute for Healthcare Improvement: December 2022.
https://psnet.ahrq.gov/issue/rise-health-coalition
Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative
for collective work to address four areas of e…
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psnet.ahrq.gov/node/50665/psn-pdf
November 13, 2019 - The SECOND Trial
November 13, 2019
Northwestern University Feinberg School of Medicine
https://psnet.ahrq.gov/issue/second-trial
Surgical resident well-being is paramount to ensuring safe surgical care and a healthy workforce. This
website shares information on the Surgical Education Culture Optimization through t…
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psnet.ahrq.gov/node/35034/psn-pdf
November 05, 2015 - Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care. Second edition.
November 5, 2015
Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute for Healthcare Improvement; 2008.
https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-car…
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psnet.ahrq.gov/node/856639/psn-pdf
November 29, 2023 - Impact Wellbeing.
November 29, 2023
National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/impact-wellbeing
Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal
provides access to too…
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psnet.ahrq.gov/node/45735/psn-pdf
July 17, 2017 - CMPA Good Practices Guide.
July 17, 2017
Ottawa, Ontario: Canadian Medical Protective Association; 2016.
https://psnet.ahrq.gov/issue/cmpa-good-practices-guide
Key patient safety topics include human factors, teamwork, adverse events, communication,
professionalism, and risk management. This website provides resou…
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psnet.ahrq.gov/node/42418/psn-pdf
May 07, 2018 - Disrespectful behavior in healthcare...have we made any
progress in the last decade?
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 27, 2013.
https://psnet.ahrq.gov/issue/disrespectful-behavior-healthcarehave-we-made-any-progress-last-decade
This newsletter article reviews studies that show how…
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psnet.ahrq.gov/node/35933/psn-pdf
July 26, 2010 - Surgical 'never events': how common are adverse
occurrences?
July 26, 2010
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk
Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
https://psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
The…
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psnet.ahrq.gov/node/34699/psn-pdf
January 04, 2017 - Organizational costs of preventable medical errors.
January 4, 2017
Weeks WB, Waldron J, Foster T, et al. The organizational costs of preventable medical errors. Jt Comm J
Qual Improv. 2001;27(10):533-9.
https://psnet.ahrq.gov/issue/organizational-costs-preventable-medical-errors
Using two composite case studies a…
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psnet.ahrq.gov/node/41808/psn-pdf
October 08, 2024 - ISMP Medication Safety Intensive.
October 8, 2024
Institute for Safe Medication Practices. December 5-6 2024, 7:30 AM - 4:30 PM (eastern).
https://psnet.ahrq.gov/issue/ismp-medication-safety-intensive
This virtual workshop will explore tactics for community and specialty pharmacies to ensure medication
safety, inc…
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psnet.ahrq.gov/node/50662/psn-pdf
November 13, 2019 - Deep Dive: Safe Ambulatory Care, Strategies for Patient
Safety & Risk Reduction.
November 13, 2019
Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/deep-dive-safe-ambulatory-care-strategies-patient-safety-risk-reduction
Outpatient safety is gaining traction as a focal point of analysis and …
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psnet.ahrq.gov/node/47658/psn-pdf
December 12, 2018 - Heartbroken.
December 12, 2018
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
https://psnet.ahrq.gov/issue/heartbroken
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious
patient safety incidents at a health care institute dedicated to treating heart pr…
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psnet.ahrq.gov/node/41165/psn-pdf
December 08, 2016 - IHI Open School Patient Safety Curriculum
December 8, 2016
Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition
There is a documented interest in postgraduate professional education that enables practicing clinicians to
improve the safety of their actions and beh…