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psnet.ahrq.gov/node/34927/psn-pdf
June 23, 2009 - Health Care Quality and Disparities: Lessons from the
First National Reports.
June 23, 2009
Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88.
https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
Highlights from AHRQ's two inaugural reports, the 2003 National …
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psnet.ahrq.gov/node/35619/psn-pdf
June 24, 2010 - Studying patient safety in health care organizations:
accentuate the qualitative.
June 24, 2010
Hoff TJ, Sutcliffe K. Studying patient safety in health care organizations: accentuate the qualitative. Jt
Comm J Qual Patient Saf. 2006;32(1):5-15.
https://psnet.ahrq.gov/issue/studying-patient-safety-health-care-organ…
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psnet.ahrq.gov/node/41390/psn-pdf
January 31, 2013 - A systematic review of patient tracking systems for use
in the pediatric emergency department.
January 31, 2013
Dobson I, Doan Q, Hung G. A systematic review of patient tracking systems for use in the pediatric
emergency department. J Emerg Med. 2013;44(1):242-8. doi:10.1016/j.jemermed.2012.02.017.
https://psnet.a…
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psnet.ahrq.gov/node/36335/psn-pdf
February 01, 2011 - Rapid response teams—walk, don't run.
February 1, 2011
Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13).
doi:10.1001/jama.296.13.1645.
https://psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run
Rapid response teams (RRTs) have been widely advocated as a means of aver…
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psnet.ahrq.gov/node/35006/psn-pdf
October 25, 2013 - HealthGrades Quality Study: Second Annual Patient
Safety in American Hospitals Study.
October 25, 2013
Health Grades, Inc; 2005.
https://psnet.ahrq.gov/issue/healthgrades-quality-study-second-annual-patient-safety-american-hospitals-
study
The first version of this now annual report on the safety of hospitalized …
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psnet.ahrq.gov/node/50860/psn-pdf
February 05, 2020 - Does team reflexivity impact teamwork and
communication in interprofessional hospital-based
healthcare teams? A systematic review and narrative
synthesis.
February 5, 2020
McHugh SK, Lawton R, O'Hara JK, et al. Does team reflexivity impact teamwork and communication in
interprofessional hospital-based healthcare …
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psnet.ahrq.gov/node/73634/psn-pdf
August 25, 2021 - Validation of an electronic trigger to measure missed
diagnosis of stroke in emergency departments.
August 25, 2021
Vaghani V, Wei L, Mushtaq U, et al. Validation of an electronic trigger to measure missed diagnosis of
stroke in emergency departments. J Am Med Inform Assoc. 2021;28(10):2202-2211.
doi:10.1093/jamia…
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psnet.ahrq.gov/node/840142/psn-pdf
November 16, 2022 - The neglected barrier to medication use: a systematic
review of difficulties associated with opening medication
packaging.
November 16, 2022
Angel M, Bechard L, Pua YH, et al. The neglected barrier to medication use: a systematic review of
difficulties associated with opening medication packaging. Age Ageing. 2022…
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psnet.ahrq.gov/node/34990/psn-pdf
June 22, 2009 - Detecting adverse drug reactions on paediatric wards:
intensified surveillance versus computerised screening of
laboratory values.
June 22, 2009
Haffner S, von Laue N, Wirth S, et al. Detecting adverse drug reactions on paediatric wards: intensified
surveillance versus computerised screening of laboratory values. …
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psnet.ahrq.gov/node/40820/psn-pdf
October 05, 2011 - Influence of house-staff experience on teaching-hospital
mortality: the "July Phenomenon" revisited.
October 5, 2011
van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital
mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7):389-94. doi:10.1002/jhm.917.
htt…
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psnet.ahrq.gov/node/42658/psn-pdf
March 17, 2014 - Systematic review of the application of the plan-do-study-
act method to improve quality in healthcare.
March 17, 2014
Taylor MJ, McNicholas C, Nicolay C, et al. Systematic review of the application of the plan-do-study-act
method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290-8. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/37805/psn-pdf
February 15, 2011 - Designing and implementing a comprehensive quality and
patient safety management model: a paradigm for
perioperative improvement.
February 15, 2011
Herzer KR, Mark LJ, Michelson JD, et al. Designing and Implementing a Comprehensive Quality and
Patient Safety Management Model. J Patient Saf. 2008;4(2). doi:10.1097/…
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psnet.ahrq.gov/node/44674/psn-pdf
December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care
at Baylor Scott & White Health.
December 18, 2017
Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
Since the publication of the Inst…
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psnet.ahrq.gov/node/45465/psn-pdf
September 07, 2016 - Improving patient safety culture in primary care: a
systematic review.
September 7, 2016
Verbakel NJ, Langelaan M, Verheij TJM, et al. Improving Patient Safety Culture in Primary Care: A
Systematic Review. J Patient Saf. 2016;12(3):152-8. doi:10.1097/PTS.0000000000000075.
https://psnet.ahrq.gov/issue/improving-pat…
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psnet.ahrq.gov/node/44624/psn-pdf
March 02, 2016 - What methods are used to apply positive deviance within
healthcare organisations? A systematic review.
March 2, 2016
Baxter R, Taylor N, Kellar I, et al. What methods are used to apply positive deviance within healthcare
organisations? A systematic review. BMJ Qual Saf. 2016;25(3):190-201. doi:10.1136/bmjqs-2015-00…
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psnet.ahrq.gov/node/46487/psn-pdf
May 16, 2018 - High Reliability for a Highly Unreliable World: Preparing
for Code Blue Through Daily Operations in Healthcare.
May 16, 2018
van Stralen D, Byrum SL, Inozu B. North Charleston, SC: CreateSpace Publishing; 2018. ISBN:
1974506371.
https://psnet.ahrq.gov/issue/high-reliability-highly-unreliable-world-preparing-code-b…
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psnet.ahrq.gov/node/37770/psn-pdf
March 10, 2011 - Identifying and quantifying medication errors: evaluation
of rapidly discontinued medication orders submitted to a
computerized physician order entry system.
March 10, 2011
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidly
discontinued medication orders su…
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psnet.ahrq.gov/node/46825/psn-pdf
June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic
errors using big data.
June 19, 2018
Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors
using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.
https://psnet.ahrq.gov/issue/diagnosti…
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psnet.ahrq.gov/node/43377/psn-pdf
April 25, 2016 - Using Lean "automation with a human touch" to improve
medication safety: a step closer to the "perfect dose."
April 25, 2016
Ching JM, Williams BL, Idemoto LM, et al. Using lean "automation with a human touch" to improve
medication safety: a step closer to the "perfect dose". Jt Comm J Qual Patient Saf. 2014;40(8):…
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psnet.ahrq.gov/node/44773/psn-pdf
January 13, 2016 - A tool for the concise analysis of patient safety incidents.
January 13, 2016
Pham JC, Hoffman C, Popescu I, et al. A Tool for the Concise Analysis of Patient Safety Incidents. Jt
Comm J Qual Patient Saf. 2016;42(1):26-33.
https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents
Once identified,…