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psnet.ahrq.gov/issue/screen-savers-adjunct-medical-education-patient-safety
March 03, 2010 - Study
Screen savers as an adjunct to medical education on patient safety.
Citation Text:
Screen savers as an adjunct to medical education on patient safety. Coil CJ; Kaji AH; Crevensten H; Aaron KE; Lewis RJ; Coates WC.
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psnet.ahrq.gov/issue/disclosure-unanticipated-events-next-step-better-communication-patients-part-1-3
January 13, 2016 - Book/Report
Disclosure of unanticipated events: the next step in better communication with patients (part 1 of 3).
Citation Text:
Disclosure of unanticipated events: the next step in better communication with patients (part 1 of 3). Chicago, IL; American Society of Healthcare Risk Ma…
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psnet.ahrq.gov/issue/teamwork-and-communication-surgical-teams-implications-patient-safety
March 25, 2020 - Study
Teamwork and communication in surgical teams: implications for patient safety.
Citation Text:
Teamwork and communication in surgical teams: implications for patient safety. Mills P; Neily J; Dunn E.
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psnet.ahrq.gov/issue/integrating-patient-safety-curriculum
July 15, 2009 - Commentary
Integrating patient safety into curriculum.
Citation Text:
Integrating patient safety into curriculum. Rapala K, Novak JC. Patient Safety Quality in Healthcare. March/April 2007.
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psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
September 07, 2022 - Audiovisual Presentation
First, Do No Harm Part 1: A Case Study of Systems Failure.
Citation Text:
First, Do No Harm Part 1: A Case Study of Systems Failure. Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000.
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psnet.ahrq.gov/issue/finding-and-preventing-patient-safety-incidents
October 25, 2013 - Book/Report
Finding and Preventing Patient Safety Incidents.
Citation Text:
Finding and Preventing Patient Safety Incidents. Golden, CO: HealthGrades, Inc.; June 9, 2014.
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psnet.ahrq.gov/issue/team-communication-operating-room
January 28, 2009 - Commentary
Team communication in the operating room.
Citation Text:
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49(7):898-901.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
June 02, 2025 - Observing Patient Care Rounds
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentinel events. Communication among disciplines can be improved if viewed through the eyes of an objective observer.
What are obser…
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psnet.ahrq.gov/issue/patient-safety-tools-primary-care
May 17, 2023 - Commentary
Patient safety tools for primary care.
Citation Text:
Patient safety tools for primary care. Domdera J. Fam Pract Manag. 2023;30(2):24-28.
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www.ahrq.gov/news/newsroom/case-studies/cquips1201.html
October 01, 2014 - AHRQ Patient Safety Surveys, TeamSTEPPS Used in Georgia Nursing Homes and Hospitals
Search All Impact Case Studies
January 2012
Alliant/GMCF, the Medicare Quality Improvement Organization (QIO) for Georgia, used AHRQ's patient safety culture surveys and team training tools in tandem to help nursing homes an…
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psnet.ahrq.gov/issue/team-training-program-using-human-factors-enhance-patient-safety
January 24, 2024 - Commentary
A team training program using human factors to enhance patient safety.
Citation Text:
Marshall DA, Manus DA. A Team Training Program Using Human Factors to Enhance Patient Safety. AORN J. 2007;86(6). doi:10.1016/j.aorn.2007.11.026.
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psnet.ahrq.gov/issue/art-apology-when-and-how-seek-forgiveness
May 17, 2023 - Commentary
The art of apology: when and how to seek forgiveness.
Citation Text:
The art of apology: when and how to seek forgiveness. Roberts RG. Fam Pract Manag. 2007;14(7):44-49.
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psnet.ahrq.gov/issue/white-blood-cell-left-shift-neonate-case-mistaken-identity
March 30, 2022 - Commentary
White blood cell left shift in a neonate: a case of mistaken identity.
Citation Text:
White blood cell left shift in a neonate: a case of mistaken identity. Mohamed IS; Wynn RJ; Cominsky K; Reynolds AM; Ryan RM; Kumar VH; Lakshminrusimha S.
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psnet.ahrq.gov/issue/becoming-high-reliability-organization
May 04, 2015 - Special or Theme Issue
Becoming a High Reliability Organization.
Citation Text:
Becoming a High Reliability Organization. VHA Forum. Summer 2020;1-12.
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psnet.ahrq.gov/issue/survey-shows-recession-has-weakened-patient-safety-net
June 10, 2018 - Newspaper/Magazine Article
Survey shows recession has weakened patient safety net.
Citation Text:
Survey shows recession has weakened patient safety net. ISMP Medication Safety Alert! Acute care edition! January 14, 2010;15:1-4.
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psnet.ahrq.gov/issue/2020-john-m-eisenberg-patient-safety-and-quality-awards
August 12, 2020 - Award Recipient
The 2020 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
The 2020 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2021;47(8):463-488.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pfengagement-senior-checklist.docx
May 01, 2017 - AHRQ Safety Program for Ambulatory Surgery
Patient and Family Engagement in the Surgical Environment Module
Senior Leader Checklist
AHRQ Safety Program for Ambulatory Surgery
Module 3: Patient and Family Engagement
Complete?
Opportunities To Engage Patients and Family
Party Responsible
Notes
Assig…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.2. Suntown Hospital
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Central Hospital
Ca…
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psnet.ahrq.gov/issue/point-care-medication-error-prevention-best-practices-action
December 24, 2007 - Newspaper/Magazine Article
Point-of-care medication error prevention: best practices in action.
Citation Text:
Point-of-care medication error prevention: best practices in action. Swenson D. Patient Safety Qual Heathc. May/June 2007.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/overview.docx
March 01, 2017 - AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Long-Term Care Safety Toolkit Modules
Overview of the Long-Term Care Safety Toolkit Modules and Nursing Home Survey on Patient Safety Culture
The Long-Term Care (LTC) Safety Toolkit is designed to support learning and implementation efforts to improve safety cult…