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psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-systematic-review
September 29, 2021 - Review
Interventions to improve team effectiveness: a systematic review.
Citation Text:
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95. doi:10.1016/j.healthpol…
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psnet.ahrq.gov/issue/applying-medications-transitions-and-clinical-handoffs-toolkit-rural-primary-care-clinic
August 04, 2021 - Study
Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers.
Citation Text:
Jarrett T, Cochran J, Baus A. Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural pr…
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psnet.ahrq.gov/issue/risk-unintentional-overdose-non-prescription-acetaminophen-products
January 22, 2014 - Study
Risk of unintentional overdose with non-prescription acetaminophen products.
Citation Text:
Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3.
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psnet.ahrq.gov/issue/hospital-testing-effectiveness-co-designed-educational-materials-improve-patient-and-visitor
February 28, 2024 - Study
Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.
Citation Text:
King L, Belan I, Clark RA, et al. Hospital testing of the effectiveness of co-designed educational m…
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psnet.ahrq.gov/issue/attending-physician-remote-access-electronic-health-record-and-implications-resident
September 22, 2010 - Study
Attending physician remote access of the electronic health record and implications for resident supervision: a mixed methods study.
Citation Text:
Martin SK, Tulla K, Meltzer DO, et al. Attending Physician Remote Access of the Electronic Health Record and Implications for Resident …
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/issue/parents-medication-administration-errors-role-dosing-instruments-and-health-literacy
May 31, 2017 - Study
Parents' medication administration errors: role of dosing instruments and health literacy.
Citation Text:
Yin S, Mendelsohn A, Wolf MS, et al. Parents' medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164(2):181-6. doi…
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psnet.ahrq.gov/issue/accuracy-patient-understanding-common-medical-phrases
November 30, 2022 - Study
Accuracy in patient understanding of common medical phrases.
Citation Text:
Gotlieb R, Praska C, Hendrickson MA, et al. Accuracy in patient understanding of common medical phrases. JAMA Netw Open. 2022;5(11):e2242972. doi:10.1001/jamanetworkopen.2022.42972.
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psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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psnet.ahrq.gov/node/40197/psn-pdf
February 09, 2011 - Professional Conduct Toolkit.
February 9, 2011
Washington, DC: US Department of Defense, Patient Safety Program.
https://psnet.ahrq.gov/issue/professional-conduct-toolkit
This toolkit provides a checklist, a planning guide, and other tools to help address disruptive staff behavior.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/39608/psn-pdf
November 21, 2016 - Institute for Patient- and Family- Centered Care.
November 21, 2016
IPFFC. PO Box 6397, McLean, VA 22106.
https://psnet.ahrq.gov/issue/institute-patient-and-family-centered-care
This organization provides a variety of resources, including webinars and implementation tools, to engage
patients and their family membe…
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psnet.ahrq.gov/node/39044/psn-pdf
March 12, 2010 - Relenza (zanamivir) inhalation powder.
March 12, 2010
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
https://psnet.ahrq.gov/issue/relenza-zanamivir-inhalation-powder
This alert notifies health care providers of the potential for patient harm if a particular inhalation po…
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psnet.ahrq.gov/node/38367/psn-pdf
May 24, 2015 - Pathways for Patient Safety.
May 24, 2015
Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group
Management Association; 2009.
https://psnet.ahrq.gov/issue/pathways-patient-safety
This trio of modules provides ambulatory medical practices with tools to develop te…
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psnet.ahrq.gov/node/35714/psn-pdf
February 15, 2006 - ACOG Committee Opinion #320: partnering with patients
to improve safety.
February 15, 2006
ACOG Committee on Quality Improvement and Patient Safety.
https://psnet.ahrq.gov/issue/acog-committee-opinion-320-partnering-patients-improve-safety
This committee opinion provides several recommendations for enhancing patie…
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psnet.ahrq.gov/node/38882/psn-pdf
November 14, 2011 - Dead by Mistake.
November 14, 2011
Crowley CF, Nalder E. New York, NY: Hearst Digital News; August 2009.
https://psnet.ahrq.gov/issue/dead-mistake
This Web site provides access to numerous materials relating stories of medical harm and reporting data
as well as contextual information from a news media investigatio…
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psnet.ahrq.gov/node/35449/psn-pdf
November 02, 2005 - Tomorrow's operating room to harness Net, RFID.
November 2, 2005
Olsen S. CNET. October 19, 2005.
https://psnet.ahrq.gov/issue/tomorrows-operating-room-harness-net-rfid
This article describes the "OR of the Future" initiative at Massachusetts General Hospital. The project uses
advanced technology to provide patien…
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psnet.ahrq.gov/node/37490/psn-pdf
January 23, 2008 - Battling hospital-acquired infections.
January 23, 2008
Gross T; Shannon R. NPR. January 9, 2008.
https://psnet.ahrq.gov/issue/battling-hospital-acquired-infections
This interview with Richard Shannon, MD, addresses the safety consequences of hospital-acquired
infections and discusses prevention tactics for health…
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psnet.ahrq.gov/node/35865/psn-pdf
July 22, 2010 - When should a leader apologize—and when not?
July 22, 2010
Kellerman B. When should a leader apologize and when not? Harv Bus Rev. 2006;84(4):72-81; 148.
https://psnet.ahrq.gov/issue/when-should-leader-apologize-and-when-not
The author provides guidance for leaders on when to publicly apologize and how to do so.
h…
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psnet.ahrq.gov/node/40631/psn-pdf
July 27, 2011 - Misdiagnosed: what to do when your doctor doesn't
know.
July 27, 2011
Fischer MA.
https://psnet.ahrq.gov/issue/misdiagnosed-what-do-when-your-doctor-doesnt-know
This magazine article discusses several cases of misdiagnosis, explores reasons for errors, and provides
tips for patients to improve safety.
https://ps…