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psnet.ahrq.gov/node/46251/psn-pdf
October 31, 2017 - A piece of my mind. Speak up.
October 31, 2017
Merrill DG. Speak Up. JAMA. 2017;317(23). doi:10.1001/jama.2017.2022.
https://psnet.ahrq.gov/issue/piece-my-mind-speak
Team support and respect are key elements of a culture of safety. This commentary highlights how
clinicians can experience disrespectful encounters w…
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psnet.ahrq.gov/node/854836/psn-pdf
August 01, 2014 - The Foundations of Safety Science.
August 1, 2014
LeCoze JC, Pettersen K, Reiman T, eds. Safety Sci. 2014;67:1-70.
https://psnet.ahrq.gov/issue/foundations-safety-science
Safety science crosses many disciplines including healthcare, aviation, and nuclear power. This special
issue describes the state of safety scie…
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psnet.ahrq.gov/node/39033/psn-pdf
October 21, 2009 - Enhancing medication use safety: benefits of learning
from your peers.
October 21, 2009
Kazandjian VA, Ogunbo S, Wicker KG, et al. Enhancing medication use safety: benefits of learning from
your peers. Qual Saf Health Care. 2009;18(5):331-5. doi:10.1136/qshc.2008.027938.
https://psnet.ahrq.gov/issue/enhancing-medi…
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psnet.ahrq.gov/node/34627/psn-pdf
December 08, 2015 - Patient & Worker Safety.
December 8, 2015
Association of periOperative Registered Nurses.
https://psnet.ahrq.gov/issue/patient-worker-safety
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses'
(AORN) patient safety initiative targeting the needs of perioperative …
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psnet.ahrq.gov/node/44492/psn-pdf
September 23, 2015 - Teamwork in Healthcare.
September 23, 2015
Fam Syst Health. 2015;33(3):175-269.
https://psnet.ahrq.gov/issue/teamwork-healthcare
Teamwork is a key element of patient-centered care, but evidence regarding its use in the primary care
environment is limited. Articles in this special issue examine the reasons for this…
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psnet.ahrq.gov/node/35281/psn-pdf
March 11, 2011 - Detection and prevention of medication errors using real-
time bedside nurse charting.
March 11, 2011
Nelson NC, Evans RS, Samore MH, et al. Detection and Prevention of Medication Errors Using Real-Time
Bedside Nurse Charting. Journal of the American Medical Informatics Association. 2005;12(4).
doi:10.1197/jamia.m…
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psnet.ahrq.gov/node/43619/psn-pdf
October 22, 2014 - The SAGES FUSE program: bridging a patient safety gap.
October 22, 2014
Fuchshuber PR, Robinson TN, Feldman LS, et al. The SAGES FUSE program: bridging a patient safety
gap. Bull Am Coll Surg. 2014;99(9):18-27.
https://psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
Surgical fires, though rare,…
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psnet.ahrq.gov/node/867648/psn-pdf
January 01, 2023 - Opioid Taskforce Playbook.
January 1, 2023
College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook.
https://psnet.ahrq.gov/issue/opioid-taskforce-playbook
Hospitals play an important role in identifying and preventing the misuse and abuse of prescription opioids.
This Opioid Playbo…
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psnet.ahrq.gov/node/42290/psn-pdf
May 22, 2013 - Safety in Numbers: Evidence-based Development of a
Medicine Management Learning Tool.
May 22, 2013
Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.
https://psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management-
learning-tool
Articles in this special issue outline the developm…
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psnet.ahrq.gov/node/38324/psn-pdf
January 14, 2009 - Effectiveness of random and focused review in detecting
surgical pathology error.
January 14, 2009
Raab SS, Grzybicki DM, Mahood LK, et al. Effectiveness of random and focused review in detecting
surgical pathology error. Am J Clin Pathol. 2008;130(6):905-12. doi:10.1309/AJCPPIA5D7MYKDWF.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/846165/psn-pdf
March 15, 2023 - Do no unconscious harm.
March 15, 2023
Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698.
https://psnet.ahrq.gov/issue/do-no-unconscious-harm
Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and
patient/physician commun…
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psnet.ahrq.gov/node/39245/psn-pdf
January 20, 2010 - Adverse Events in Hospitals: Public Disclosure of
Information About Events.
January 20, 2010
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
January 5, 2010. Report No. OEI-06-09-00360.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-public-disclosure-in…
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psnet.ahrq.gov/node/37094/psn-pdf
February 01, 2011 - Improving patient care by linking evidence-based
medicine and evidence-based management.
February 1, 2011
Shortell SM, Rundall TG, Hsu J. Improving Patient Care by Linking Evidence-Based Medicine and
Evidence-Based Management. JAMA. 2007;298(6). doi:10.1001/jama.298.6.673.
https://psnet.ahrq.gov/issue/improving-pa…
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psnet.ahrq.gov/node/42603/psn-pdf
March 04, 2015 - Cognitive and system factors contributing to diagnostic
errors in radiology.
March 4, 2015
Lee CS, Nagy PG, Weaver SJ, et al. Cognitive and system factors contributing to diagnostic errors in
radiology. AJR Am J Roentgenol. 2013;201(3):611-7. doi:10.2214/AJR.12.10375.
https://psnet.ahrq.gov/issue/cognitive-and-sys…
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psnet.ahrq.gov/node/60855/psn-pdf
August 26, 2020 - The paradoxes of defensive medicine.
August 26, 2020
Saks MJ, Landsman S. Health Matrix: J Law-Med. 2020;30(1):25-84.
https://psnet.ahrq.gov/issue/paradoxes-defensive-medicine
Defensive medicine behaviors seeking to avoid malpractice risk due to care omissions challenge patient
safety and value narratives. This le…
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psnet.ahrq.gov/node/60627/psn-pdf
June 24, 2020 - Second opinions improve healthcare outcomes and
reduce costs.
June 24, 2020
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News.
2020;June 8.
https://psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
Second opinions are a strategy for redu…
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psnet.ahrq.gov/node/837981/psn-pdf
August 31, 2022 - Improving medication reconciliation in hospitals.
August 31, 2022
Schnipper JL. Ann Intern Med. 2022;175(8):ho2-ho3.
https://psnet.ahrq.gov/issue/improving-medication-reconciliation-hospitals
Medication reconciliation is a primary method for improving the safety of medication administration in acute
care. Thi…
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psnet.ahrq.gov/node/38486/psn-pdf
March 18, 2009 - Medical errors in orthopaedics. Results of an AAOS
member survey.
March 18, 2009
Wong DA, Herndon JH, Canale T, et al. Medical errors in orthopaedics. Results of an AAOS member
survey. J Bone Joint Surg Am. 2009;91(3):547-57. doi:10.2106/JBJS.G.01439.
https://psnet.ahrq.gov/issue/medical-errors-orthopaedics-result…
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psnet.ahrq.gov/node/37017/psn-pdf
September 15, 2011 - The association between culture, climate and quality of
care in primary health care teams.
September 15, 2011
Hann M, Bower P, Campbell S, et al. The association between culture, climate and quality of care in
primary health care teams. Fam Pract. 2007;24(4):323-9.
https://psnet.ahrq.gov/issue/association-between-…
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psnet.ahrq.gov/node/37739/psn-pdf
June 07, 2008 - Health-Care-Associated Infections in Hospitals:
Leadership Needed from HHS to Prioritize Prevention
Practices and Improve Data on these Infections.
June 7, 2008
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-
283.
https://psnet.ahrq.gov/issue/health-care-associa…