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psnet.ahrq.gov/issue/ashp-statement-pharmacists-role-medication-reconciliation
June 30, 2021 - Commentary
ASHP statement on the pharmacist's role in medication reconciliation.
Citation Text:
ASHP Statement on the Pharmacist’s Role in Medication Reconciliation. Am J Health Syst Pharm. 2013;70(5):453-456. doi:10.2146/sp120009.
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psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical-practice
November 17, 2021 - Newspaper/Magazine Article
Intravenous (IV) push medications – bridging the gap between education and clinical practice.
Citation Text:
Intravenous (IV) push medications – bridging the gap between education and clinical practice. ISMP Medication Safety Alert! Acute Care. November 2, …
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psnet.ahrq.gov/issue/how-avoid-seven-deadly-sins-surgery
June 17, 2014 - Commentary
How to avoid the 'seven deadly sins of surgery.'
Citation Text:
Kirby R, Challacombe B, Dasgupta P, et al. How to avoid the 'seven deadly sins of surgery'. BJU Int. 2012;109(2):171-3. doi:10.1111/j.1464-410X.2011.10802.x.
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psnet.ahrq.gov/issue/patients-went-hospital-care-after-testing-positive-there-covid-some-never-came-out
January 26, 2022 - Newspaper/Magazine Article
Patients went into the hospital for care. After testing positive there for Covid, some never came out.
Citation Text:
Patients went into the hospital for care. After testing positive there for Covid, some never came out. Jewett C. Kaiser Health News. November 4…
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psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations
June 28, 2023 - Newspaper/Magazine Article
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.
Citation Text:
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations. Blau M. STAT. April 20, 2018…
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psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby
September 01, 2010 - Newspaper/Magazine Article
Hospital bosses ignored months of doctors' warnings about Lucy Letby.
Citation Text:
Hospital bosses ignored months of doctors' warnings about Lucy Letby. Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
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psnet.ahrq.gov/issue/using-simulation-training-improve-perioperative-patient-safety
August 20, 2018 - Study
Using simulation training to improve perioperative patient safety.
Citation Text:
Mullen L, Byrd D. Using simulation training to improve perioperative patient safety. AORN J. 2013;97(4):419-27. doi:10.1016/j.aorn.2013.02.001.
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psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment
October 27, 2021 - Newspaper/Magazine Article
Air pressure: human factors are the key to a safer flight environment.
Citation Text:
Air pressure: human factors are the key to a safer flight environment. Erich J. EMS World. April 2019;48:26-31.
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psnet.ahrq.gov/issue/briefings-checklists-geese-and-surgical-safety
August 02, 2015 - Commentary
Briefings, checklists, geese, and surgical safety.
Citation Text:
Karl R. Briefings, checklists, geese, and surgical safety. Ann Surg Oncol. 2010;17(1):8-11. doi:10.1245/s10434-009-0794-9.
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psnet.ahrq.gov/issue/medication-error-reduction-and-use-pda-technology
August 28, 2024 - Study
Medication error reduction and the use of PDA technology.
Citation Text:
Greenfield S. Medication error reduction and the use of PDA technology. J Nurs Educ. 2007;46(3):127-31. doi:10.3928/01484834-20070301-07.
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psnet.ahrq.gov/issue/quantifying-distraction-and-interruption-urological-surgery
March 11, 2009 - Study
Quantifying distraction and interruption in urological surgery.
Citation Text:
Healey A, Primus CP, Koutantji M. Quantifying distraction and interruption in urological surgery. Qual Saf Health Care. 2007;16(2):135-9.
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psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error
August 23, 2023 - Commentary
Poor physician-patient communication and medical error.
Citation Text:
Poor physician-patient communication and medical error. Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
June 02, 2025 - Job Aid: Process Mapping
Primary Care Practice Facilitator
Training Series
1
Job Aid: Process Mapping
Overview
Process mapping, also called workflow mapping, allows a practice to "see" an entire work
process from beginning to end.
When to use process mapping
Use process mapping to help a p…
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psnet.ahrq.gov/issue/color-coding-reduce-errors
June 22, 2009 - Commentary
Color coding to reduce errors.
Citation Text:
Deboer S, Seaver M, Broselow J. Color coding to reduce errors. Am J Nurs. 2005;105(8):68-71.
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psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
January 15, 2020 - Review
There's a science for that: team development interventions in organizations.
Citation Text:
Shuffler ML, DiazGranados D, Salas E. There’s a Science for That. Curr Dir Psychol Sci. 2011;20(6). doi:10.1177/0963721411422054.
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psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
February 14, 2024 - Commentary
Why your TeamSTEPPS program may not be working.
Citation Text:
Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs. 2012;9(8). doi:10.1016/j.ecns.2012.03.007.
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psnet.ahrq.gov/issue/staying-safe-simple-tools-safe-surgery
August 02, 2015 - Commentary
Staying safe: simple tools for safe surgery.
Citation Text:
Karl RC. Staying safe: simple tools for safe surgery. Bull Am Coll Surg. 2007;92(4):16-22.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitator-roadmap.pdf
February 01, 2022 - Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement
Facilitator’s Implementation Roadmap:
TeamSTEPPS® Diagnosis Improvement
This implementation roadmap provides an overview of the steps a course facilitator should follow
for implementing the TeamSTEPPS® for Diagnosis Improvement Course and the …
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psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
May 15, 2024 - Commentary
Antimicrobial stewardship and patient safety.
Citation Text:
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356. doi:10.1016/j.aorn.2016.08.002.
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www.ahrq.gov/teamstepps-program/curriculum/team/overview/index.html
May 01, 2023 - Section 1: Overview of Key Communication Concepts and Tools
This section provides an overview of the key concepts and tools in the Team Leadership Module. More explanations and illustrations are provided in section 2 of this module ; section 3 includes methods for teaching the concepts and tools for this modu…