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psnet.ahrq.gov/node/46291/psn-pdf
July 26, 2017 - Experiences with Lean Six Sigma as improvement
strategy to reduce parenteral medication administration
errors and associated potential risk of harm.
July 26, 2017
van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to
reduce parenteral medication administration erro…
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psnet.ahrq.gov/node/845353/psn-pdf
March 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a
Patient at the Chico Community-Based Outpatient Clinic
in California.
March 1, 2023
Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.
https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and…
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psnet.ahrq.gov/node/72473/psn-pdf
January 01, 2021 - Resilience vs. vulnerability: psychological safety and
reporting of near misses with varying proximity to harm in
radiation oncology.
November 18, 2020
Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: psychological safety and reporting of
near misses with varying proximity to harm in radiation …
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psnet.ahrq.gov/node/865930/psn-pdf
May 22, 2024 - Operational failures in general practice: a consensus-
building study on the priorities for improvement.
May 22, 2024
Sinnott C, Alboksmaty A, Moxey JM, et al. Operational failures in general practice: a consensus-building
study on the priorities for improvement. Br J Gen Pract. 2024;74(742):e339-e346.
doi:10.3399…
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psnet.ahrq.gov/node/45192/psn-pdf
December 04, 2016 - Evidence summary and recommendations for improved
communication during care transitions.
December 4, 2016
Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved
Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/851651/psn-pdf
July 26, 2023 - Using failure mode and effect analysis to identify
potential failures in a psychiatric hospital emergency
department.
July 26, 2023
Gur-Arieh S, Mendlovic S, Rozenblum R, et al. Using failure mode and effect analysis to identify potential
failures in a psychiatric hospital emergency department. J Patient Saf. 2023…
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psnet.ahrq.gov/node/46255/psn-pdf
September 06, 2017 - Patient Safety in the Home: Assessment of Issues,
Challenges, and Opportunities.
September 6, 2017
Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities
The ambulatory env…
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psnet.ahrq.gov/node/37585/psn-pdf
April 29, 2010 - Medication errors involving patient-controlled analgesia.
April 29, 2010
Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health
Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194.
https://psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-a…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
July 01, 2023 - Labor and Delivery Unit Staff Safety Assessment
AHRQ Safety Program for Perinatal Care
Purpose: To tap into the knowledge and experiences of labor and delivery (L&D) providers and other clinical and nonclinical staff (e.g., health unit coordinators and environmental services personnel) to find ou…
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psnet.ahrq.gov/node/863753/psn-pdf
March 06, 2024 - Towards a common framework to support decision-
making in high-risk, low-time environments.
March 6, 2024
Launder D, Penney G. Towards a common framework to support decision?making in high?risk, low?time
environments. J Contin Crisis Manag. 2023;31(4):862-876. doi:10.1111/1468-5973.12487.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45836/psn-pdf
July 02, 2017 - Improving patient safety: avoiding unread imaging exams
in the National VA enterprise electronic health record.
July 2, 2017
Bastawrous S, Carney B. Improving Patient Safety: Avoiding Unread Imaging Exams in the National VA
Enterprise Electronic Health Record. J Digit Imaging. 2017;30(3):309-313. doi:10.1007/s10278…
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psnet.ahrq.gov/node/41045/psn-pdf
July 02, 2014 - Relating faults in diagnostic reasoning with diagnostic
errors and patient harm.
July 2, 2014
Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient
harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6.
https://psnet.ahrq.gov/issue/relating-fau…
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psnet.ahrq.gov/node/43141/psn-pdf
April 30, 2014 - Engaging residents and fellows to improve institution-
wide quality: the first six years of a novel financial
incentive program.
April 30, 2014
Vidyarthi A, Green AL, Rosenbluth G, et al. Engaging residents and fellows to improve institution-wide
quality: the first six years of a novel financial incentive program.…
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psnet.ahrq.gov/node/865972/psn-pdf
May 29, 2024 - Development and evaluation of patient safety
interventions: perspectives of operational safety leaders
and patient safety organizations.
May 29, 2024
Gomes KM, Handley J, Pruitt ZM, et al. Development and evaluation of patient safety interventions:
perspectives of operational safety leaders and patient safety orga…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-19.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 1.19. Major Factors that Inhibit Lean Success at LHC
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare …
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psnet.ahrq.gov/node/44033/psn-pdf
April 22, 2015 - Quality improvements in decreasing medication
administration errors made by nursing staff in an
academic medical center hospital: a trend analysis during
the journey to Joint Commission International
accreditation and in the post-accreditation era.
April 22, 2015
Wang H-F, Jin J-F, Feng X-Q, et al. Quality improv…
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psnet.ahrq.gov/node/837148/psn-pdf
May 18, 2022 - Assessing quality of older persons' emergency
transitions between long-term and acute care settings: a
proof-of-concept study.
May 18, 2022
Tate K, McLane P, Reid C, et al. Assessing quality of older persons’ emergency transitions between long-
term and acute care settings: a proof-of-concept study. BMJ Open Qual.…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
March 01, 2017 - T.E.A.M.S. infographic
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Culture consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes, and staff satisfaction.
Culture influences how change can occur.
T
Team Formation
The most effective…
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psnet.ahrq.gov/node/865592/psn-pdf
April 17, 2024 - Associations between organizational communication and
patients' experience of prolonged emotional impact
following medical errors.
April 17, 2024
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Associations between organizational communication and
patients' experience of prolonged emotional impact following medica…
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psnet.ahrq.gov/node/836929/psn-pdf
April 13, 2022 - The impact of "missed nursing care" or "care not done"
on adults in health care: a rapid review for the Consensus
Development Project.
April 13, 2022
Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid
review for the Consensus Development Project. Nurs Open. …