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psnet.ahrq.gov/node/39551/psn-pdf
May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac surgery.
May 26, 2010
Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac surgery. Anest…
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psnet.ahrq.gov/node/47088/psn-pdf
May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018
User Database Report.
May 2, 2018
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2018. AHRQ Publication No. 18-0030-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…
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psnet.ahrq.gov/node/42900/psn-pdf
September 19, 2016 - Suicide attempts and completions on medical-surgical
and intensive care units.
September 19, 2016
Mills PD, Watts V, Hemphill RR. Suicide attempts and completions on medical-surgical and intensive care
units. J Hosp Med. 2014;9(3):182-5. doi:10.1002/jhm.2141.
https://psnet.ahrq.gov/issue/suicide-attempts-and-compl…
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - Investigating the association of alerts from a national
mortality surveillance system with subsequent hospital
mortality in England: an interrupted time series analysis.
November 21, 2018
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national mortality
surveillance system with …
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psnet.ahrq.gov/node/39583/psn-pdf
October 30, 2010 - The harm susceptibility model: a method to prioritise
risks identified in patient safety reporting systems.
October 30, 2010
Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks
identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5.
…
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psnet.ahrq.gov/node/40092/psn-pdf
December 22, 2010 - The value of adding a verbal report to written handoffs on
early readmission following prolonged respiratory failure.
December 22, 2010
Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early
readmission following prolonged respiratory failure. Chest. 2010;138(6):14…
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psnet.ahrq.gov/node/44711/psn-pdf
September 21, 2016 - The well-defined pediatric ICU: active surveillance using
nonmedical personnel to capture less serious safety
events.
September 21, 2016
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using
Nonmedical Personnel to Capture Less Serious Safety Events. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/44064/psn-pdf
November 03, 2015 - The July effect: an analysis of never events in the
nationwide inpatient sample.
November 3, 2015
Wen T, Attenello FJ, Wu B, et al. The July effect: an analysis of never events in the nationwide inpatient
sample. J Hosp Med. 2015;10(7):432-438. doi:10.1002/jhm.2352.
https://psnet.ahrq.gov/issue/july-effect-analysi…
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psnet.ahrq.gov/node/45882/psn-pdf
June 28, 2017 - Early death after discharge from emergency departments:
analysis of national US insurance claims data.
June 28, 2017
Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis
of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.
https://psnet.a…
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psnet.ahrq.gov/node/39822/psn-pdf
February 17, 2011 - The disclosure dilemma—large-scale adverse events.
February 17, 2011
Dudzinski DM, Hébert PC, Foglia MB, et al. The disclosure dilemma--large-scale adverse events. New Engl
J Med. 2010;363(10):978-986. doi:10.1056/NEJMhle1003134.
https://psnet.ahrq.gov/issue/disclosure-dilemma-large-scale-adverse-events
Error disc…
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psnet.ahrq.gov/node/45681/psn-pdf
January 25, 2017 - Economic evaluation of quality improvement
interventions for bloodstream infections related to central
catheters: a systematic review.
January 25, 2017
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for
Bloodstream Infections Related to Central Catheters: A Systema…
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psnet.ahrq.gov/node/46599/psn-pdf
August 20, 2018 - Effect of standardized handoff curriculum on improved
clinician preparedness in the intensive care unit: a
stepped-wedge cluster randomized clinical trial.
August 20, 2018
Parent B, LaGrone LN, Albirair MT, et al. Effect of Standardized Handoff Curriculum on Improved Clinician
Preparedness in the Intensive Care Un…
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psnet.ahrq.gov/node/44766/psn-pdf
January 23, 2017 - Why do we still page each other? Examining the
frequency, types and senders of pages in academic
medical services.
January 23, 2017
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and
senders of pages in academic medical services. BMJ Qual Saf. 2017;26(1):24-29. do…
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psnet.ahrq.gov/node/45483/psn-pdf
March 20, 2018 - Impact of initial hospital diagnosis on mortality for acute
myocardial infarction: a national cohort study.
March 20, 2018
Wu J, Gale CP, Hall M, et al. Editor's Choice - Impact of initial hospital diagnosis on mortality for acute
myocardial infarction: A national cohort study. Eur Heart J Acute Cardiovasc Care. 20…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/node/39082/psn-pdf
January 04, 2010 - Communication practices on 4 Harvard surgical
services: a surgical safety collaborative.
January 4, 2010
Elbardissi AW, Regenbogen SE, Greenberg CC, et al. Communication practices on 4 Harvard surgical
services: a surgical safety collaborative. Ann Surg. 2009;250(6):861-5.
doi:10.1097/SLA.0b013e3181afe0db.
https:…
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/43253/psn-pdf
May 01, 2015 - Interim Report: Review of VHA's Patient Wait Times,
Scheduling Practices, and Alleged Patient Deaths at the
Phoenix Health Care System.
May 1, 2015
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
https://psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-s…
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psnet.ahrq.gov/node/41557/psn-pdf
August 01, 2012 - Signal and noise: applying a laboratory trigger tool to
identify adverse drug events among primary care
patients.
August 1, 2012
Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse
drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…