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psnet.ahrq.gov/node/45305/psn-pdf
February 14, 2017 - Sustaining reductions in central line-associated
bloodstream infections in Michigan intensive care units: a
10-year analysis.
February 14, 2017
Pronovost P, Watson S, Goeschel CA, et al. Sustaining Reductions in Central Line-Associated
Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis. Am…
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psnet.ahrq.gov/node/38900/psn-pdf
January 03, 2017 - Dropping the baton during the handoff from emergency
department to primary care: pediatric asthma continuity
errors.
January 3, 2017
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary
care: pediatric asthma continuity errors. Jt Comm J Qual Patient Saf. 2009;35(9):467…
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psnet.ahrq.gov/node/37544/psn-pdf
June 16, 2011 - Differences in safety climate among hospital anesthesia
departments and the effect of a realistic simulation-based
training program.
June 16, 2011
Cooper JB, Blum RH, Carroll JS, et al. Differences in safety climate among hospital anesthesia
departments and the effect of a realistic simulation-based training progr…
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psnet.ahrq.gov/node/39837/psn-pdf
September 15, 2010 - The efficacy of medical team training: improved team
performance and decreased operating room delays: a
detailed analysis of 4863 cases.
September 15, 2010
Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and
decreased operating room delays: a detailed analysis of 4863 c…
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psnet.ahrq.gov/node/46313/psn-pdf
December 21, 2017 - Patient outcomes in dose reduction or discontinuation of
long-term opioid therapy: a systematic review.
December 21, 2017
Frank JW, Lovejoy TI, Becker WC, et al. Patient Outcomes in Dose Reduction or Discontinuation of Long-
Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017;167(3):181-191. doi:10.7326/…
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psnet.ahrq.gov/node/42966/psn-pdf
November 21, 2018 - The next organizational challenge: finding and addressing
diagnostic error.
November 21, 2018
Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing
diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10.
https://psnet.ahrq.gov/issue/next-organizational-challe…
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psnet.ahrq.gov/node/41175/psn-pdf
December 31, 2014 - Design and implementation of an automated email
notification system for results of tests pending at
discharge.
December 31, 2014
Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification
system for results of tests pending at discharge. J Am Med Inform Assoc. 2012;19(4):52…
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psnet.ahrq.gov/node/43690/psn-pdf
March 26, 2015 - Improving healthcare systems' disclosures of large-scale
adverse events: a Department of Veterans Affairs
leadership, policymaker, research and stakeholder
partnership.
March 26, 2015
Elwy R, Bokhour BG, Maguire EM, et al. Improving healthcare systems' disclosures of large-scale adverse
events: a Department of Ve…
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psnet.ahrq.gov/issue/pharmacists-play-key-role-patient-safety
March 29, 2023 - Newspaper/Magazine Article
Pharmacists play key role in patient safety.
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March 6, 2005
Description of a successful model from Duke…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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psnet.ahrq.gov/node/46504/psn-pdf
February 22, 2018 - How guiding coalitions promote positive culture change
in hospitals: a longitudinal mixed methods interventional
study.
February 22, 2018
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in
hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf. 2…
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psnet.ahrq.gov/node/40601/psn-pdf
September 29, 2017 - A policy-based intervention for the reduction of
communication breakdowns in inpatient surgical care:
results from a Harvard surgical safety collaborative.
September 29, 2017
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of
communication breakdowns in inpatient surg…
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psnet.ahrq.gov/node/40946/psn-pdf
January 19, 2012 - Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad
for Optimal Patient Safety (TOPS) project.
January 19, 2012
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad f…
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psnet.ahrq.gov/node/47407/psn-pdf
January 01, 2020 - Resource-based view on safety culture's influence on
hospital performance: the moderating role of electronic
health record implementation.
September 19, 2018
Upadhyay S, Weech-Maldonado R, Lemak CH, et al. Resource-based view on safety culture’s influence on
hospital performance: The moderating role of electronic …
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psnet.ahrq.gov/node/44471/psn-pdf
September 27, 2016 - Two sides of the safety coin?: how patient engagement
and safety climate jointly affect error occurrence in
hospital units.
September 27, 2016
Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety
climate jointly affect error occurrence in hospital units. Health Care …
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psnet.ahrq.gov/node/43419/psn-pdf
October 20, 2014 - Impact of a reengineered electronic error-reporting
system on medication event reporting and care process
improvements at an urban medical center.
October 20, 2014
McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication
event reporting and care process improvements …
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psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - Association between implementation of a medical team
training program and surgical mortality.
July 3, 2014
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training
program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506.
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
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In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Vogus T, Lee M, Mos…
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February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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