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psnet.ahrq.gov/node/43868/psn-pdf
February 04, 2015 - Implementing a standardized safe surgery program
reduces serious reportable events.
February 4, 2015
Loftus T, Dahl D, OHare B, et al. Implementing a standardized safe surgery program reduces serious
reportable events. J Am Coll Surg. 2015;220(1):12-17.e3. doi:10.1016/j.jamcollsurg.2014.09.018.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-15.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.15. Major Factors that Inhibited Lean Success
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Cas…
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psnet.ahrq.gov/node/852803/psn-pdf
August 23, 2023 - Sentinel Event Alert 67: Preserving Patient Safety After a
Cyberattack.
August 23, 2023
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf.
2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006.
https://psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-sa…
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psnet.ahrq.gov/node/39834/psn-pdf
July 02, 2014 - Improving resident education and patient safety: a
method to balance initial caseloads at academic year-end
transfer.
July 2, 2014
Young JQ, Niehaus B, Lieu SC, et al. Improving resident education and patient safety: a method to balance
initial caseloads at academic year-end transfer. Acad Med. 2010;85(9):1418-24.…
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psnet.ahrq.gov/node/39064/psn-pdf
October 28, 2009 - Use of failure mode and effects analysis for proactive
identification of communication and handoff failures from
organ procurement to transplantation.
October 28, 2009
Steinberger DM, Douglas S, Kirschbaum MS. Use of failure mode and effects analysis for proactive
identification of communication and handoff failur…
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psnet.ahrq.gov/node/74693/psn-pdf
January 26, 2022 - Including the reason for use on prescriptions sent to
pharmacists: scoping review.
January 26, 2022
Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists:
scoping review. JMIR Hum Factors. 2021;8(4):e22325. doi:10.2196/22325.
https://psnet.ahrq.gov/issue/including-re…
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psnet.ahrq.gov/node/46206/psn-pdf
August 02, 2017 - Patient safety in dentistry: development of a candidate
'never event' list for primary care.
August 2, 2017
Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care.
Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/44088/psn-pdf
May 13, 2015 - Safety culture and care: a program to prevent surgical
errors.
May 13, 2015
Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors.
AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002.
https://psnet.ahrq.gov/issue/safety-culture-and-care-program-prev…
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psnet.ahrq.gov/node/33890/psn-pdf
January 04, 2017 - The faces of errors: a case-based approach to educating
providers, policy makers, and the public about patient
safety.
January 4, 2017
Wachter R, Shojania KG. The faces of errors: a case-based approach to educating providers,
policymakers, and the public about patient safety. Jt Comm J Qual Saf. 2004;30(12):665-67…
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psnet.ahrq.gov/node/60626/psn-pdf
June 24, 2020 - A nursing home’s 64-day Covid siege: ‘They’re all going
to die’.
June 24, 2020
Barker K. A nursing home’s 64-day Covid siege: ‘They’re all going to die’. New York Times. 2020;June 10.
https://psnet.ahrq.gov/issue/nursing-homes-64-day-covid-siege-theyre-all-going-die
This feature story describes the COVID-19 experi…
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psnet.ahrq.gov/node/46392/psn-pdf
October 13, 2018 - The clinical and medicolegal implications of radiology
results communication.
October 13, 2018
Aryal B, Khorsand DA, Dubinsky TJ. The Clinical and Medicolegal Implications of Radiology Results
Communication. Curr Probl Diagn Radiol. 2018;47(5):287-289. doi:10.1067/j.cpradiol.2017.09.009.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38996/psn-pdf
March 04, 2011 - Overcoming barriers to the implementation of a pharmacy
bar code scanning system for medication dispensing: a
case study.
March 4, 2011
Nanji KC, Cina J, Patel N, et al. Overcoming barriers to the implementation of a pharmacy bar code
scanning system for medication dispensing: a case study. J Am Med Inform Assoc. …
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psnet.ahrq.gov/node/60034/psn-pdf
March 11, 2020 - Responding to unprofessional behavior by trainees - a
"just culture" framework.
March 11, 2020
Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just
Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591.
https://psnet.ahrq.gov/issue/resp…
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psnet.ahrq.gov/node/47546/psn-pdf
November 14, 2018 - Why doctors hate their computers.
November 14, 2018
Gawande A. New Yorker. November 12, 2018.
https://psnet.ahrq.gov/issue/why-doctors-hate-their-computers
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as
digitization becomes more widespread in health care. He elabo…
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psnet.ahrq.gov/node/45846/psn-pdf
January 07, 2019 - Medication safety in the operating room: literature and
expert-based recommendations.
January 7, 2019
Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert-
based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew379.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39618/psn-pdf
August 03, 2010 - Characteristics and predictors of missed opportunities in
lung cancer diagnosis: an electronic health record-based
study.
August 3, 2010
Singh H, Hirani K, Kadiyala H, et al. Characteristics and predictors of missed opportunities in lung cancer
diagnosis: an electronic health record-based study. J Clin Oncol. 2010…
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psnet.ahrq.gov/node/837075/psn-pdf
May 11, 2022 - Lessons Learned from the COVID-19 Pandemic to
Improve Diagnosis. Proceedings of a Workshop–in Brief.
May 11, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2022.
https://psnet.ahrq.gov/issue/lessons-learned-covid-19-pandemic-improve-diagnosis-proceedin…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-13.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 5.13. Project Team Composition—Pediatric Continuity of Care
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Heal…
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psnet.ahrq.gov/node/43178/psn-pdf
July 28, 2014 - Safety measurement and monitoring in healthcare: a
framework to guide clinical teams and healthcare
organisations in maintaining safety.
July 28, 2014
Vincent CA, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide
clinical teams and healthcare organisations in maintaining s…