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psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
August 01, 2018 - Commentary
Classic
"Going solid": a model of system dynamics and consequences for patient safety.
Citation Text:
Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4.
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psnet.ahrq.gov/issue/no-shortcuts-safer-opioid-prescribing
March 30, 2016 - Commentary
Classic
No shortcuts to safer opioid prescribing.
Citation Text:
Dowell D, Haegerich T, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med. 2019;380(24):2285-2287. doi:10.1056/NEJMp1904190.
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psnet.ahrq.gov/issue/using-opportunity-estimator-tool-improve-engagement-quality-and-safety-intervention
August 25, 2010 - Commentary
Using the opportunity estimator tool to improve engagement in a quality and safety intervention.
Citation Text:
Duval-Arnould J, Mathews SC, Weeks K, et al. Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention. Jt Comm J Qual Patien…
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psnet.ahrq.gov/issue/utilizing-systems-and-design-thinking-approach-improving-well-being-within-health
March 10, 2021 - Book/Report
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Citation Text:
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. Kreit…
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psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
August 13, 2014 - Study
Managing clinical failure: a complex adaptive system perspective.
Citation Text:
Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336.
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psnet.ahrq.gov/issue/evidence-based-red-cell-transfusion-critically-ill-quality-improvement-using-computerized
February 15, 2017 - Study
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.
Citation Text:
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician …
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psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
December 13, 2017 - Newspaper/Magazine Article
Prescribing errors in children: why they happen and how to prevent them.
Citation Text:
Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184…
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psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-vigilance
April 06, 2022 - Newspaper/Magazine Article
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance.
Citation Text:
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance. Webb J. Drug Topics. March 10, 2015.
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psnet.ahrq.gov/issue/association-resident-fatigue-and-distress-perceived-medical-errors
February 02, 2011 - Study
Association of resident fatigue and distress with perceived medical errors.
Citation Text:
West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389.
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psnet.ahrq.gov/issue/relationship-between-patients-perceptions-team-effectiveness-and-their-care-experience
June 08, 2011 - Study
The relationship between patients' perceptions of team effectiveness and their care experience in the emergency department.
Citation Text:
Kipnis A, Rhodes K, Burchill CN, et al. The relationship between patients' perceptions of team effectiveness and their care experience in the…
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - Study
Quality improvement to decrease specimen mislabeling in transfusion medicine.
Citation Text:
Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198.
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psnet.ahrq.gov/issue/sentara-norfolk-general-hospital-accelerating-improvement-focusing-building-culture-safety
June 08, 2010 - Commentary
Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety.
Citation Text:
Yates GR, Hochman RF, Sayles SM, et al. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Jt Comm J Qu…
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psnet.ahrq.gov/issue/teaching-quality-improvement
July 19, 2023 - Commentary
Teaching quality improvement.
Citation Text:
Murray ME, Douglas S, Girdley D, et al. Teaching quality improvement. J Nurs Educ. 2010;49(8):466-9. doi:10.3928/01484834-20100430-09.
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psnet.ahrq.gov/issue/contribution-nurses-incident-disclosure-narrative-review
March 15, 2016 - Review
The contribution of nurses to incident disclosure: a narrative review.
Citation Text:
Harrison R, Birks Y, Hall J, et al. The contribution of nurses to incident disclosure: a narrative review. Int J Nurs Stud. 2014;51(2):334-45. doi:10.1016/j.ijnurstu.2013.07.001.
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psnet.ahrq.gov/issue/patient-safety-what-how-and-when
June 23, 2021 - Commentary
Patient safety: the what, how, and when.
Citation Text:
Albrecht RM. Patient safety: the what, how, and when. Am J Surg. 2015;210(6):978-82. doi:10.1016/j.amjsurg.2015.09.003.
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www.ahrq.gov/es/programs/index.html?page=2
Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
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psnet.ahrq.gov/issue/strategies-flipping-script-opioid-overprescribing
May 29, 2019 - Commentary
Strategies for flipping the script on opioid overprescribing.
Citation Text:
Wright AP, Becker WC, Schiff G. Strategies for Flipping the Script on Opioid Overprescribing. JAMA Intern Med. 2016;176(1):7-8. doi:10.1001/jamainternmed.2015.5946.
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psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
November 28, 2018 - Book/Report
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health.
Citation Text:
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health. Silver Spring, MD: US Food and Drug Administration; April 2018.
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psnet.ahrq.gov/issue/medical-error-and-decision-making-learning-past-and-present-intensive-care
June 26, 2024 - Review
Medical error and decision making: learning from the past and present in intensive care.
Citation Text:
Bucknall TK. Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 2010;23(3). doi:10.1016/j.aucc.2010.06.001.
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psnet.ahrq.gov/issue/creating-safer-operating-room-groups-team-dynamics-and-crew-resource-management-principles
June 11, 2008 - Review
Emerging Classic
Creating a safer operating room: groups, team dynamics and crew resource management principles.
Citation Text:
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource management principles. Semin Pe…