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psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution
April 08, 2011 - Commentary
Classic
Anesthetic mishaps: breaking the chain of accident evolution.
Citation Text:
Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66(5):670-6.
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psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care
April 17, 2013 - Study
Failure-to-rescue: comparing definitions to measure quality of care.
Citation Text:
Silber JH, Romano PS, Rosen AK, et al. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007;45(10):918-25.
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psnet.ahrq.gov/issue/reporting-and-classification-patient-safety-events-cardiothoracic-intensive-care-unit-and
August 02, 2011 - Study
Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.
Citation Text:
Nast PA, Avidan M, Harris CB, et al. Reporting and classification of patient safety events in a cardiothoracic intensive care uni…
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psnet.ahrq.gov/issue/reducing-health-care-hazards-lessons-commercial-aviation-safety-team
September 17, 2010 - Commentary
Reducing health care hazards: lessons from the Commercial Aviation Safety Team.
Citation Text:
Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hl…
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psnet.ahrq.gov/issue/identifying-facilitators-and-barriers-patient-safety-medicine-label-design-system-using
July 23, 2018 - Study
Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews.
Citation Text:
Dieckmann P, Clemmensen MH, Sørensen TK, et al. Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design Sys…
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psnet.ahrq.gov/issue/physician-motivation-listening-what-pay-performance-programs-and-quality-improvement
January 02, 2017 - Commentary
Physician motivation: listening to what pay-for-performance programs and quality improvement collaboratives are telling us.
Citation Text:
Herzer KR, Pronovost P. Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Te…
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psnet.ahrq.gov/issue/safety-academic-medical-center-transforming-challenges-ingredients-improvement
February 17, 2011 - Review
Safety in the academic medical center: transforming challenges into ingredients for improvement.
Citation Text:
Blumenthal D, Ferris T. Safety in the academic medical center: transforming challenges into ingredients for improvement. Acad Med. 2006;81(9):817-22.
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psnet.ahrq.gov/issue/workforce-perceptions-hospital-safety-culture-development-and-validation-patient-safety
November 18, 2009 - Study
Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.
Citation Text:
Singer SJ, Meterko M, Baker LC, et al. Workforce perceptions of hospital safety culture: development and validation of the…
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psnet.ahrq.gov/issue/comparing-safety-climate-naval-aviation-and-hospitals-implications-improving-patient-safety
October 14, 2009 - Study
Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.
Citation Text:
Singer SJ, Rosen AK, Zhao S, et al. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health Care Manag Rev. 2010…
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psnet.ahrq.gov/issue/improving-communication-and-resolution-following-adverse-events-using-patient-created
September 01, 2018 - Study
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Citation Text:
Gallagher TH, Etchegaray J, Bergstedt B, et al. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. H…
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psnet.ahrq.gov/issue/patient-safety-examining-adequacy-5-rights-medication-administration
March 02, 2016 - Commentary
Patient safety: examining the adequacy of the 5 rights of medication administration.
Citation Text:
Macdonald M. Patient safety: examining the adequacy of the 5 rights of medication administration. Clin Nurse Spec. 2010;24(4):196-201. doi:10.1097/NUR.0b013e3181e3605f.
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psnet.ahrq.gov/issue/structural-empowerment-and-patient-safety-culture-among-registered-nurses-working-adult
January 23, 2008 - Study
Structural empowerment and patient safety culture among registered nurses working in adult critical care units.
Citation Text:
Armellino D, Griffin MTQ, Fitzpatrick JJ. Structural empowerment and patient safety culture among registered nurses working in adult critical care units.…
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psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
June 19, 2024 - Commentary
Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.
Citation Text:
Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.20…
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psnet.ahrq.gov/issue/time-accelerate-integration-human-factors-and-ergonomics-patient-safety
October 03, 2013 - Commentary
Time to accelerate integration of human factors and ergonomics in patient safety.
Citation Text:
Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421.
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psnet.ahrq.gov/issue/listening-and-question-asking-behaviors-resident-and-nurse-handoff-conversations-prospective
June 27, 2018 - Study
Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.
Citation Text:
Kannampallil TG, Abraham J. Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.…
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psnet.ahrq.gov/issue/missed-breast-cancer-effects-subconscious-bias-and-lesion-characteristics
February 02, 2022 - Commentary
Missed breast cancer: effects of subconscious bias and lesion characteristics.
Citation Text:
Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.202019009…
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psnet.ahrq.gov/issue/hospira-issues-voluntary-nationwide-recall-one-lot-05-bupivacaine-hydrochloride-injection-usp
June 20, 2018 - Press Release/Announcement
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling.
Citation Text:
Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivaca…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/about-toolkit.html
May 01, 2017 - About the Toolkit Development
Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities
The toolkit was developed based on the experiences of approximately 500 nursing homes across the country that participated in the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI, a 3-year implementation projec…
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psnet.ahrq.gov/issue/role-safety-culture-influencing-provider-perceptions-patient-safety
November 09, 2016 - Study
The role of safety culture in influencing provider perceptions of patient safety.
Citation Text:
Bishop A, Boyle TA. The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety. J Patient Saf. 2016;12(4):204-209.
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psnet.ahrq.gov/issue/effect-blue-enriched-lighting-medical-error-rate-university-hospital-icu
March 10, 2021 - Study
The effect of blue-enriched lighting on medical error rate in a university hospital ICU.
Citation Text:
Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j…