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psnet.ahrq.gov/issue/can-positivity-promote-safety-psychological-capital-development-combats-cynicism-and-unsafe
June 09, 2011 - Study
Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior.
Citation Text:
Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. d…
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psnet.ahrq.gov/issue/what-causes-adverse-events-prehospital-care-human-factors-approach
July 26, 2023 - Study
What causes adverse events in prehospital care? A human-factors approach.
Citation Text:
Price R, Bendall JC, Patterson JA, et al. What causes adverse events in prehospital care? A human-factors approach. Emerg Med J. 2013;30(7):583-8. doi:10.1136/emermed-2011-200971.
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psnet.ahrq.gov/issue/contribution-sociotechnical-factors-health-information-technology-related-sentinel-events
September 18, 2024 - Study
The contribution of sociotechnical factors to health information technology–related sentinel events.
Citation Text:
Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/issue/preventing-medication-errors-information-age
February 15, 2023 - Commentary
Preventing medication errors in the information age.
Citation Text:
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-58. doi:10.1097/01.NURSE.0000544230.51598.38.
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psnet.ahrq.gov/issue/fool-me-twice-delayed-diagnoses-radiology-emphasis-perpetuated-errors
July 08, 2020 - Study
Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors.
Citation Text:
Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol. 2014;202(3):465-70. doi:10.2214/AJR.13.11493.
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psnet.ahrq.gov/issue/medication-safety-issue-brief-small-and-rural-hospitals-unique-challenges-unique-solutions
June 17, 2014 - Fact Sheet/FAQs
Medication safety issue brief. Small and rural hospitals—unique challenges, unique solutions.
Citation Text:
Association AH, Pharmacists AS of H-S, Networks H & H. Medication Safety Issue Brief. Small and rural hospitals--unique challenges, unique solutions. Hospitals & h…
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psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
October 19, 2022 - Commentary
Preparing challenging medications for barcode scanning.
Citation Text:
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454.
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psnet.ahrq.gov/issue/adapting-joint-commissions-seven-foundations-safe-and-effective-transitions-care-home
July 10, 2024 - Commentary
Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home.
Citation Text:
Labson MC. Adapting the joint commission's seven foundations of safe and effective transitions of care to home. Home Healthc Now. 2015;33(3):142-6. doi:10.1097/N…
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psnet.ahrq.gov/issue/does-your-patient-really-understand
January 25, 2023 - Newspaper/Magazine Article
Does your patient really understand?
Citation Text:
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
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psnet.ahrq.gov/issue/addressing-postdischarge-adverse-events-neglected-area
November 13, 2024 - Review
Addressing postdischarge adverse events: a neglected area.
Citation Text:
Tsilimingras D. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Patient Saf. 2008;34(2):85-97.
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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psnet.ahrq.gov/issue/oncology-care-setting-design-and-planning-part-i-concepts-oncology-nurse-improve-patient
September 24, 2010 - Commentary
Oncology care setting design and planning part I: concepts for the oncology nurse that improve patient safety.
Citation Text:
Sheridan-Leos N. Oncology care setting design and planning part I: Concepts for the oncology nurse that improve patient safety. Clin J Oncol Nurs. 20…
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psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting-medecins-sans
December 21, 2022 - Study
Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières.
Citation Text:
Shanks L, Bil K, Fernhout J. Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières. PLoS One. 20…
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psnet.ahrq.gov/issue/next-phase-health-care-improvement-what-can-we-learn-social-movements
July 22, 2010 - Commentary
The next phase of health care improvement: what can we learn from social movements?
Citation Text:
Bate P, Robert G, Bevan H. The next phase of healthcare improvement: what can we learn from social movements? Qual Saf Health Care. 2004;13(1):62-6.
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psnet.ahrq.gov/issue/nuclear-power-industry-alternative-analogy-safety-anaesthesia-and-novel-approach
February 13, 2019 - Commentary
The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.
Citation Text:
Webster CS. The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for t…
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psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
July 01, 2016 - Study
Sentinel events. In memory of Ben—a case study.
Citation Text:
Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5.
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psnet.ahrq.gov/issue/your-code-cart-ready
August 30, 2017 - Newspaper/Magazine Article
Is your code cart ready?
Citation Text:
Cohen ML. Is your code cart ready? Medical economics. 2005;82(18):45-6, 48.
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psnet.ahrq.gov/issue/linking-nurse-characteristics-team-member-effectiveness-practice-environment-and-medication
May 14, 2008 - Study
Linking nurse characteristics, team member effectiveness, practice environment, and medication error incidence.
Citation Text:
Fasolino T, Snyder R. Linking nurse characteristics, team member effectiveness, practice environment, and medication error incidence. J Nurs Care Qual. 2…
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www.ahrq.gov/topics/training.html
Topic: Training
AHRQ offers training toolkits on topics such as teamwork, reducing healthcare-associated infections, and improving safety.
AHRQ Research Training and Career Development Opportunities: Overview
Development of the Learning Health System Researcher Core…
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www.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
July 01, 2023 - Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams
YouTube embedded video: https://www.youtube-nocookie.com/embed/ekX289e3-Uo
TeamSTEPPS: Check-Back in Inpatient Surgical Teams (15 seconds)
Checking to ensure medication instructions are described—and heard—correctly is an important saf…