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  1. Looking to the future of patient safety. | PSNet

    psnet.ahrq.gov/issue/looking-future-patient-safety
    February 13, 2018 - July 29, 2009 System issues leading to "found-on-floor" incidents: a multi-incident analysis

  2. Too exhausted to act safely? | PSNet

    psnet.ahrq.gov/issue/too-exhausted-act-safely
    June 28, 2016 - May 20, 2019 Leading change: why transformation efforts fail.

  3. Gap assessment of hospitals' adoption of the just culture principles. | PSNet

    psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles
    September 21, 2005 - February 13, 2019 Leading a highly visible hospital through a serious reportable event

  4. After the Error: Speaking Out About Patient Safety to Save Lives. | PSNet

    psnet.ahrq.gov/issue/after-error-speaking-out-about-patient-safety-save-lives
    February 04, 2009 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.

  5. Nurses' role in detecting deterioration in ward patients: systematic literature review. | PSNet

    psnet.ahrq.gov/issue/nurses-role-detecting-deterioration-ward-patients-systematic-literature-review
    March 27, 2018 - August 4, 2010 Leading successful rapid response teams: a multisite implementation evaluation

  6. JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings. | PSNet

    psnet.ahrq.gov/issue/jcaho-launch-global-patient-safety-center-initial-focus-will-be-reviewing-and-publicizing
    December 22, 2010 - 14, 2011 View More Related Resources Mental health conditions leading

  7. On the Edge: Nursing in the Age of Complexity. | PSNet

    psnet.ahrq.gov/issue/edge-nursing-age-complexity
    August 20, 2012 - February 17, 2010 Cascade iatrogenesis: factors leading to the development of adverse

  8. How to master the new art of training: teamwork on the fly. | PSNet

    psnet.ahrq.gov/issue/how-master-new-art-training-teamwork-fly
    June 28, 2011 - May 29, 2019 Leading change: why transformation efforts fail.

  9. Inattentional blindness: what captures your attention? | PSNet

    psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention
    May 07, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

  10. "Superficial" Report Leads to "Deep" Problem | PSNet

    psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
    July 01, 2012 - this case, the DVT label in the final report either triggered recognition or generated new knowledge leading

  11. Are we finally getting serious about medical errors? | PSNet

    psnet.ahrq.gov/issue/are-we-finally-getting-serious-about-medical-errors
    May 11, 2016 - February 11, 2015 System issues leading to "found-on-floor" incidents: a multi-incident

  12. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. | PSNet

    psnet.ahrq.gov/issue/wall-silence-untold-story-medical-mistakes-kill-and-injure-millions-americans
    January 30, 2003 - July 18, 2024 Leading change: why transformation efforts fail.

  13. Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare. | PSNet

    psnet.ahrq.gov/issue/safety-culture-building-and-sustaining-cultural-change-aviation-and-healthcare
    August 02, 2016 - December 18, 2017 Leading a Culture of Safety: a Blueprint for Success.

  14. ISMP updates its list of drug name pairs with Tall man letters. | PSNet

    psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
    June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

  15. The Habits of an Improver. Thinking About Learning for Improvement in Health Care. | PSNet

    psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care
    November 25, 2015 - September 20, 2016 Leading High-Reliability Organizations in Healthcare.

  16. Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development. | PSNet

    psnet.ahrq.gov/issue/healthcare-quality-and-safety-workforce-report-new-imperatives-quality-and-safety-mean-new
    May 06, 2015 - September 3, 2024 Leading a Culture of Safety: a Blueprint for Success.

  17. The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding. | PSNet

    psnet.ahrq.gov/issue/role-non-icu-staff-nurse-medical-emergency-team-perceptions-and-understanding
    April 12, 2006 - August 4, 2010 Leading successful rapid response teams: a multisite implementation evaluation

  18. Keeping patients on track with preventative care during pandemic. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-track-preventative-care-during-pandemic
    April 11, 2018 - June 17, 2020 Mental health conditions leading cause of pregnancy-related deaths.

  19. A clinical reminder about the safe use of insulin vials. | PSNet

    psnet.ahrq.gov/issue/clinical-reminder-about-safe-use-insulin-vials
    June 10, 2018 - May 7, 2018 National estimates of insulin-related hypoglycemia and errors leading to

  20. Promote a culture of safety with good catch reports. | PSNet

    psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports
    November 06, 2015 - July 18, 2018 Why are medical errors still a leading cause of death?
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