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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
August 10, 2025 - In this commentary, leaders of... … In this commentary, leaders of several leading safety organizations endorse five principles for transforming
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - therapists, physical therapists, social workers, case management staff,
and pharmacy staff)
Establishing leaders … Role-based leaders with relevant experience and subject matter expertise (e.g., nurses, physicians,
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - buy-in from key partners, like physicians, nurses, families,
frontline staff, and senior and unit leaders … first step in developing this innovation
is to identify champions, like families and organization leaders
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - rapid growth of the hospitalist model—both within and outside academic hospitals—seems to indicate that leaders … trainees understand the importance of their roles as both providers of care for individual patients and as leaders
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psnet.ahrq.gov/issue/effects-patient-safety-culture-interventions-incident-reporting-general-practice-cluster
September 07, 2016 - Study
Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial.
Citation Text:
Verbakel NJ, Langelaan M, Verheij TJM, et al. Effects of patient safety culture interventions on incident reporting in general practice: a cluster r…
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psnet.ahrq.gov/issue/study-error-reporting-nurses-significant-impact-nursing-team-dynamics
April 12, 2014 - Study
A study of error reporting by nurses: the significant impact of nursing team dynamics.
Citation Text:
Munn LT, Lynn MR, Knafl GJ, et al. A study of error reporting by nurses: the significant impact of nursing team dynamics. J Res Nurs. 2023;28(5):354-364. doi:10.1177/17449871231194…
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psnet.ahrq.gov/issue/collaborative-learning-network-approach-improvement-cusp-learning-network
July 21, 2017 - Commentary
A collaborative learning network approach to improvement: the CUSP learning network.
Citation Text:
Weaver SJ, Lofthus J, Sawyer M, et al. A Collaborative Learning Network Approach to Improvement: The CUSP Learning Network. Jt Comm J Qual Patient Saf. 2015;41(4):147-159.
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psnet.ahrq.gov/issue/surfacing-safety-hazards-using-standardized-operating-room-briefings-and-debriefings-large
January 03, 2017 - Study
Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.
Citation Text:
Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional …
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psnet.ahrq.gov/issue/racial-ethnic-and-socioeconomic-disparities-patient-safety-events-hospitalized-children
August 14, 2018 - Study
Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.
Citation Text:
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1…
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psnet.ahrq.gov/issue/understanding-knowledge-gaps-whistleblowing-and-speaking-health-care-narrative-reviews
September 11, 2018 - Book/Report
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Citation Text:
Understanding the knowledge gaps in whistleblowing and speaking up…
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psnet.ahrq.gov/issue/implementing-standardized-operating-room-briefings-and-debriefings-large-regional-medical
January 03, 2017 - Study
Implementing standardized operating room briefings and debriefings at a large regional medical center.
Citation Text:
Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qua…
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psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care
February 07, 2018 - Study
Developing, implementing, evaluating electronic apparent cause analysis across a health care system.
Citation Text:
Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-after-adverse-events
May 18, 2022 - Study
When clinicians drop out and start over after adverse events.
Citation Text:
Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008.
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psnet.ahrq.gov/issue/good-people-who-try-their-best-can-have-problems-recognition-human-factors-and-how-minimise
October 29, 2017 - Review
Good people who try their best can have problems: recognition of human factors and how to minimise error.
Citation Text:
Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition of human factors and how to minimise error. Br J Oral Ma…
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psnet.ahrq.gov/issue/serious-experience-events-applying-patient-safety-concepts-improve-patient-experience
August 04, 2021 - Commentary
Serious experience events: applying patient safety concepts to improve patient experience.
Citation Text:
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety concepts to improve patient experience. J Patient Exp. 2022;9:23743735…
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psnet.ahrq.gov/node/46902/psn-pdf
August 20, 2018 - Researchers conducted interviews with 165 frontline staff and senior leaders working at three
academic … They found that leaders viewed formal systems for raising concerns
favorably, but other respondents
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psnet.ahrq.gov/node/40166/psn-pdf
April 03, 2017 - This set of articles offers a strategic framework for
leaders to address conflict as a key component … 2, the authors focus on designing a process for managing conflict and developing competencies for
leaders
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015096-davison-final-report-2008.pdf
January 01, 2008 - Hospital leaders
reported that this module had few problems. … TDH leaders thought that staff accepted the new systems
fairly well. … The gradual implementation process was perceived as useful by
most leaders. … All hospital leaders expressed frustration with this system. … TDH leaders should be proud of their accomplishments during this grant.
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - The survey results were a wake-up call for the organization's leaders. … First, a small group of 10 key clinical and operational leaders attended a day-long session with David … The leaders who attended enthusiastically embraced the just culture concept, finding that it provides … Leaders must ask hard questions like, "How prevalent is this behavior? Why are people doing this? … Leaders must establish processes to know when someone is engaging in reckless behavior and be willing
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - Developing these hospital staffing plans requires a complex dance involving nurse leaders, staff nurses … Accordingly, nurse leaders and their designees must develop strategies to deal with these absences to … It is the responsibility of the board of trustees and senior leaders to empower the Chief Nurse to design … Nurse unit leaders must anticipate changing staffing needs and assess at least 4-8 hours prior to the … As budgets tighten, it is vital that nurse leaders maintain RN ratios when census is high and decrease