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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
htt…
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psnet.ahrq.gov/node/41983/psn-pdf
January 16, 2013 - A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness.
January 16, 2013
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and
clinical safety and effectiveness. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-0015…
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psnet.ahrq.gov/node/41775/psn-pdf
December 18, 2014 - Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool.
December 18, 2014
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
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psnet.ahrq.gov/node/44560/psn-pdf
January 23, 2017 - What is the return on investment for implementation of a
crew resource management program at an academic
medical center?
January 23, 2017
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a
Crew Resource Management Program at an Academic Medical Center? Am J Med…
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psnet.ahrq.gov/node/43174/psn-pdf
December 12, 2014 - Adverse drug event detection in pediatric oncology and
hematology patients: using medication triggers to identify
patient harm in a specialized pediatric patient population.
December 12, 2014
Call RJ, Burlison JD, Robertson JJ, et al. Adverse drug event detection in pediatric oncology and
hematology patients: usin…
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psnet.ahrq.gov/node/46910/psn-pdf
January 23, 2019 - Taking the heat or taking the temperature? A qualitative
study of a large-scale exercise in seeking to measure for
improvement, not blame.
January 23, 2019
Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualitative study of
a large-scale exercise in seeking to measure for i…
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psnet.ahrq.gov/node/43904/psn-pdf
October 13, 2015 - Reducing unacceptable missed doses: pharmacy
assistant–supported medicine administration.
October 13, 2015
Baqir W, Jones K, Horsley W, et al. Reducing unacceptable missed doses: pharmacy assistant-supported
medicine administration. Int J Pharm Pract. 2015;23(5):327-332. doi:10.1111/ijpp.12172.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/38621/psn-pdf
February 18, 2011 - Process of care failures in breast cancer diagnosis.
February 18, 2011
Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen
Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0.
https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
Di…
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psnet.ahrq.gov/node/43766/psn-pdf
September 26, 2016 - Driven to distraction: a prospective controlled study of a
simulated ward round experience to improve patient
safety teaching for medical students.
September 26, 2016
Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward
round experience to improve patient saf…
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psnet.ahrq.gov/node/72824/psn-pdf
March 10, 2021 - Association of a Safety Program for Improving Antibiotic
Use with antibiotic use and hospital-onset Clostridioides
difficile infection rates among US hospitals
March 10, 2021
Tamma PD, Miller MA, Dullabh P, et al. Association of a safety program for improving antibiotic use with
antibiotic use and hospital-onset C…
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psnet.ahrq.gov/node/840141/psn-pdf
November 16, 2022 - Toward zero harm: Mackenzie Health's journey toward
becoming a high reliability organization and eliminating
avoidable harm.
November 16, 2022
Wilson M-A, Sinno M, Hacker Teper M, et al. Toward zero harm: Mackenzie Health's journey toward
becoming a high reliability organization and eliminating avoidable harm. J P…
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psnet.ahrq.gov/node/45562/psn-pdf
October 12, 2016 - Characterising the nature of primary care patient safety
incident reports in the England and Wales National
Reporting and Learning System: a mixed-methods
agenda-setting study for general practice.
October 12, 2016
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising The Nature Of Primary Care Patient Sa…
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psnet.ahrq.gov/node/47092/psn-pdf
October 13, 2018 - Organizational response to known medical errors: does
peer review protection impede improvement?
October 13, 2018
Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection
Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1062860618769429.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/867143/psn-pdf
November 13, 2024 - A virtual breakthrough series collaborative for missed
test results: a stepped-wedge cluster-randomized clinical
trial.
November 13, 2024
Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test
results: a stepped-wedge cluster-randomized clinical trial. JAMA Netw Open.…
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - MB: We have five major strategies going forward. The first is patient safety.
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psnet.ahrq.gov/node/47058/psn-pdf
August 20, 2018 - The first U.S. study on nurses' evidence-based practice
competencies indicates major deficits that threaten
healthcare quality, safety, and patient outcomes.
August 20, 2018
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. The First U.S. Study on Nurses' Evidence-Based Practice
Competencies Indicates Major Deficit…
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psnet.ahrq.gov/node/46323/psn-pdf
October 29, 2017 - Use of unit-based interventions to improve the quality of
care for hospitalized medical patients: a national survey.
October 29, 2017
O'Leary KJ, Johnson J, Manojlovich M, et al. Use of Unit-Based Interventions to Improve the Quality of
Care for Hospitalized Medical Patients: A National Survey. Jt Comm J Qual Patie…
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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/43785/psn-pdf
May 01, 2015 - Evaluation of the effectiveness of a surgical checklist in
Medicare patients.
May 1, 2015
Reames BN, Scally CP, Thumma JR, et al. Evaluation of the Effectiveness of a Surgical Checklist in
Medicare Patients. Med Care. 2015;53(1):87-94. doi:10.1097/MLR.0000000000000277.
https://psnet.ahrq.gov/issue/evaluation-effec…
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psnet.ahrq.gov/node/47152/psn-pdf
October 12, 2018 - A quality initiative: a system-wide reduction in serious
medication events through targeted simulation training.
October 12, 2018
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious
Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330…