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psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
July 01, 2016 - Commentary
Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.
Citation Text:
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …
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psnet.ahrq.gov/issue/beyond-communication-role-standardized-protocols-changing-health-care-environment
October 12, 2011 - Study
Beyond communication: the role of standardized protocols in a changing health care environment.
Citation Text:
Vardaman JM, Cornell P, Gondo MB, et al. Beyond communication: the role of standardized protocols in a changing health care environment. Health Care Manage Rev. 2012;37…
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psnet.ahrq.gov/issue/how-policy-makers-can-smooth-way-communication-and-resolution-programs
December 19, 2018 - Commentary
How policy makers can smooth the way for communication-and-resolution programs.
Citation Text:
Sage WM, Gallagher TH, Armstrong S, et al. How policy makers can smooth the way for communication-and- resolution programs. Health Aff (Millwood). 2014;33(1):11-9. doi:10.1377/hlthaf…
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psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
February 18, 2011 - Commentary
Critical conversations: a call for a nonprocedural "time out."
Citation Text:
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
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psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
March 17, 2021 - Commentary
Enhancing the effectiveness of team debriefings in medical simulation: more best practices.
Citation Text:
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…
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psnet.ahrq.gov/issue/safety-i-safety-ii-and-resilience-engineering
December 16, 2015 - Commentary
Safety-I, Safety-II and resilience engineering.
Citation Text:
Patterson M, Deutsch ES. Safety-I, Safety-II and resilience engineering. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):382-389. doi:10.1016/j.cppeds.2015.10.001.
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psnet.ahrq.gov/issue/hospital-performance-trends-national-quality-measures-and-association-joint-commission
September 20, 2011 - Study
Hospital performance trends on national quality measures and the association with Joint Commission accreditation.
Citation Text:
Schmaltz SP, Williams SC, Chassin MR, et al. Hospital performance trends on national quality measures and the association with joint commission accre…
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psnet.ahrq.gov/issue/diagnosing-overdiagnosis-conceptual-challenges-and-suggested-solutions
September 20, 2023 - Commentary
Diagnosing overdiagnosis: conceptual challenges and suggested solutions.
Citation Text:
Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol. 2014;29(9):599-604. doi:10.1007/s10654-014-9920-5.
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D…
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psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
January 23, 2012 - Commentary
The ongoing quality improvement journey: next stop, high reliability.
Citation Text:
Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076.
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psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
August 27, 2008 - Study
The effect of drug concentration expression on epinephrine dosing errors: a randomized trial.
Citation Text:
Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med. 2008;148(1):11-4.
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psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
May 09, 2018 - Book/Report
Classic
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Citation Text:
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Robins NS…
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psnet.ahrq.gov/issue/utilizing-improvement-science-methods-improve-physician-compliance-proper-hand-hygiene
April 13, 2011 - Study
Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
Citation Text:
White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129(4):e1042-50.…
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psnet.ahrq.gov/issue/nursing-and-physician-attire-possible-source-nosocomial-infections
July 01, 2016 - Study
Nursing and physician attire as possible source of nosocomial infections.
Citation Text:
Wiener-Well Y, Galuty M, Rudensky B, et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39(7):555-9. doi:10.1016/j.ajic.2010.12.016.
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psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patient-safety
August 04, 2021 - Commentary
Does a unit shift report "blackout" period improve patient safety?
Citation Text:
Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8-10. doi:10.1097/01.NUMA.0000553500.85897.51.
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psnet.ahrq.gov/issue/patient-safety-and-interprofessional-education-report-key-issues-two-interprofessional
August 20, 2018 - Commentary
Patient safety and interprofessional education: a report of key issues from two interprofessional workshops.
Citation Text:
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from two interprofessional workshops. J Interprof Ca…
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psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patients
July 20, 2016 - Commentary
Redesigning surgical decision making for high-risk patients.
Citation Text:
Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538.
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psnet.ahrq.gov/issue/elimination-emergency-department-medication-errors-due-estimated-weights
July 08, 2020 - Commentary
Elimination of emergency department medication errors due to estimated weights.
Citation Text:
Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5…
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psnet.ahrq.gov/issue/pediatric-medication-safety-emergency-department-0
November 19, 2018 - Organizational Policy/Guidelines
Pediatric medication safety in the emergency department.
Citation Text:
Benjamin L, Frush K, Shaw KN, et al. Pediatric Medication Safety in the Emergency Department. Ann Emerg Med. 2018;71(3):e17-e24. doi:10.1016/j.annemergmed.2017.12.013.
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psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD, MPH
April 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…