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psnet.ahrq.gov/node/43938/psn-pdf
March 18, 2015 - Fixing a broken EHR: HIM working in the spotlight to
solve common EHR issues.
March 18, 2015
Butler M. J AHIMA. March 2015;86:18-23.
https://psnet.ahrq.gov/issue/fixing-broken-ehr-him-working-spotlight-solve-common-ehr-issues
Although health information technology presents opportunities to improve patient safety, …
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psnet.ahrq.gov/node/40281/psn-pdf
August 25, 2011 - Effects of a clinical pharmacist service on health-related
quality of life and prescribing of drugs: a randomised
controlled trial.
August 25, 2011
Bladh L, Ottosson E, Karlsson J, et al. Effects of a clinical pharmacist service on health-related quality of
life and prescribing of drugs: a randomised controlled tr…
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psnet.ahrq.gov/node/44615/psn-pdf
November 04, 2015 - Implementing an obstetric emergency team response
system: overcoming barriers and sustaining response
dose.
November 4, 2015
Richardson MG, Domaradzki KA, McWeeney DT. Implementing an Obstetric Emergency Team Response
System: Overcoming Barriers and Sustaining Response Dose. Jt Comm J Qual Patient Saf.
2015;41(11…
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psnet.ahrq.gov/node/44638/psn-pdf
May 18, 2016 - Developing an appreciation of patient safety: analysis of
interprofessional student experiences with health
mentors.
May 18, 2016
Langlois S. Developing an appreciation of patient safety: analysis of interprofessional student experiences
with health mentors. Perspect Med Educ. 2016;5(2):88-94. doi:10.1007/s40037-0…
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psnet.ahrq.gov/node/866411/psn-pdf
July 31, 2024 - Simulation to Improve Patient Safety: Getting Started.
July 31, 2024
Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for
Healthcare Research and Quality; July 2024. Publication No. 24-0055.
https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…
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psnet.ahrq.gov/node/60016/psn-pdf
March 04, 2020 - The influence of bullying on nursing practice errors: a
systematic review.
March 4, 2020
Johnson AH, Benham?Hutchins M. The Influence of Bullying on Nursing Practice Errors: A Systematic
Review. AORN J. 2020;111(2). doi:10.1002/aorn.12923.
https://psnet.ahrq.gov/issue/influence-bullying-nursing-practice-errors-sys…
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digital.ahrq.gov/organization/cincinnati-childrens-hospital-medical-center
January 01, 2023 - Cincinnati Children's Hospital Medical Center
Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients
Description
This research prospectively evaluated a machine learning algorithm that identifies candidates for neurologic surgery to control epilepsy.
Gr…
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psnet.ahrq.gov/node/46609/psn-pdf
January 01, 2020 - The impact of adverse events on clinicians: what's in a
name?
April 3, 2019
Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J
Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256.
https://psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name
…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - Respectful Management of Serious Clinical Adverse
Events. Second Edition.
September 19, 2016
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement;
2011.
https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
This white paper e…
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psnet.ahrq.gov/node/60032/psn-pdf
March 11, 2020 - Medical teamwork and the evolution of safety science: a
critical review.
March 11, 2020
Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical
review. Cogn Technol Work. 2020;22(1):13-27. doi:10.1007/s10111-019-00545-8.
https://psnet.ahrq.gov/issue/medical-teamwork-and-…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/46020/psn-pdf
July 21, 2017 - Towards high-reliability organising in healthcare: a
strategy for building organisational capacity.
July 21, 2017
Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for
building organisational capacity. BMJ Qual Saf. 2017;26(8):663-670. doi:10.1136/bmjqs-2016-00624…
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psnet.ahrq.gov/node/46682/psn-pdf
January 24, 2018 - AHRQ Safety Program for Surgery.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No.
16(18)-0004-1-EF.
https://psnet.ahrq.gov/issue/ahrq-safety-program-surgery
Large-scale collaboratives have achieved success in implementing patient safety improvements. T…
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psnet.ahrq.gov/node/46640/psn-pdf
August 08, 2018 - IDEA4PS: the development of a research-oriented
learning healthcare system.
August 8, 2018
Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented
Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.
https://psnet.ahrq.gov/issue/idea4ps-…
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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
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psnet.ahrq.gov/node/50888/psn-pdf
February 12, 2020 - Preventable closed claims in the AANA Foundation
closed malpractice claims database.
February 12, 2020
Kremer MJ, Hirsch M, Geisz-Everson M, et al. Preventable Closed Claims in the AANA Foundation Closed
Malpractice Claims Database. AANA J. 2019;87(6).
https://psnet.ahrq.gov/issue/preventable-closed-claims-aana-fo…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015280-hsu-final-report-2008.pdf
January 01, 2008 - of ambulatory health information technology (HIT) on quality,
safety, and resource use in a large, integrated … These measures
5
represent areas for which the Integrated Delivery System (IDS) has clinical … Using automated databases in a large, prepaid integrated delivery system, we
examined the proportion … Mailed survey to all primary care clinicians working in a large, integrated delivery
system (IDS) in … Variation in Chronic Disease Care in Primary Care Teams of a Large Integrated
Delivery System.