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psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
September 26, 2016 - September 26, 2016
Just Culture and its critical link to patient safety—part 1 and part … February 13, 2019
IV push medications survey results—part 1 and part 2. … , 2018
Raising the index of suspicion: red flags that represent credible threats to patient … June 10, 2018
Results of ISMP survey on high-alert medications: differences between nursing … medication errors in "high-risk" patients.
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psnet.ahrq.gov/issue/mentoring-staff-members-patient-safety-leaders-clarian-safe-passage-program
January 10, 2011 - Mentoring staff members as patient safety leaders: the Clarian Safe Passage Program. … safety programs: building safe passage for patients, nurses, and clinical staff. … November 20, 2024
ASPEN survey of parenteral nutrition access issues: how the system … fails the patients. … April 10, 2024
Patient reasoning: patients' and care partners' perceptions of diagnostic
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psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes
May 26, 2011 - This survey study found that practicing radiologists and their departments have an opportunity to learn … commentary discussed a radiology "wet read" error that led to administration of thrombolytics in a patient … November 12, 2014
Inappropriate preinjury warfarin use in trauma patients: a call for … Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient … Mortality and morbidity meetings: an untapped resource for improving the governance of patient
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www.ahrq.gov/news/events/nac/2019-07-nac/nacmtg0719-minutes.html
November 01, 2019 - We must focus on the whole person patient. … to support the enhancement of provider information and data resources and will be expanding provider surveys … Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety … culture survey. … Focusing on high-cost patients does not necessarily save money.
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psnet.ahrq.gov/issue/saying-sorry-some-strategies-effective-apology-within-workplace
August 11, 2021 - Effective apology behaviors improve opportunities for error resolution for clinicians , patients, … August 11, 2021
Ethical issues in patient safety research: a systematic review of the … March 31, 2021
The safety of emergency care systems: results of a survey of clinicians … June 25, 2010
Improving hospital safety culture for falls prevention through interdisciplinary … based on feedback from former psychiatric patients.
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psnet.ahrq.gov/issue/compliance-who-surgical-safety-checklist-deviations-and-possible-improvements
September 29, 2017 - A cross-sectional survey of patient perceptions and beliefs. … February 4, 2015
EAU policy on live surgery events. … February 22, 2023
Patient involvement for improved patient safety: a qualitative study … April 1, 2015
Impact of the World Health Organization's Surgical Safety Checklist on … safety culture in the operating theatre: a controlled intervention study.
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psnet.ahrq.gov/issue/proposed-2022-cdc-clinical-practice-guideline-prescribing-opioids-notice-centers-disease
December 21, 2022 - Agency Information Collection Activities: Proposed Collection; Comment Request, "Hospital Survey … on Patient Safety Culture Comparative Database.'' … opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large … April 17, 2019
Could CDC guidelines be driving some opioid patients to suicide? … March 20, 2019
Request for comments on the proposed measures and 2020 targets for the
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psnet.ahrq.gov/issue/developing-person-centred-analysis-harm-paediatric-hospital-quality-improvement-report
September 23, 2020 - Through an iterative process, researchers developed and tested a simple tool for patients and family … improvements in staff reporting and other safety behaviors, but there was no measurable change in safety … culture scores for the ward during the study period. … the Huddle Observation Tool for structured case management discussions to improve situation awareness on … December 14, 2016
A national physician survey of diagnostic error in paediatrics.
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psnet.ahrq.gov/issue/implementing-smart-infusion-pumps-dose-error-reduction-software-real-world-experiences
May 26, 2021 - Smart pumps play an important role in preventing medication errors, but they can also introduce patient … August 28, 2019
Patient Safety: Emerging Applications of Safety Science. … - an international survey. … July 10, 2024
Family medicine presence on labor and delivery: effect on safety culture … March 27, 2024
Overnight stay in the emergency department and mortality in older patients
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psnet.ahrq.gov/node/73988/psn-pdf
October 20, 2021 - relationship between high-reliability practice and
hospital-acquired conditions among the Solutions for
Patient … relationship between high-reliability practice and
hospital-acquired conditions among the Solutions for Patient … This survey of 25 pediatric organizations
participating in a patient safety collaborative identified … an inverse association between safety culture and
patient harm, but found that elements of high-reliability … , leadership, and process improvement were not
associated with reduced patient harm.
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psnet.ahrq.gov/issue/automated-dispensing-cabinets
September 27, 2010 - Drawing on Patient Safety Authority reports, this commentary discusses common errors with automated … August 28, 2019
Improved safety culture and teamwork climate are associated with decreases … 23, 2020
Raising the alarm: a cross-sectional study exploring the factors affecting patients … ' willingness to escalate care on surgical wards. … Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey
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psnet.ahrq.gov/issue/saying-im-sorry-error-disclosure-ophthalmologists
November 20, 2019 - November 20, 2019
The correlation between neonatal intensive care unit safety culture … September 29, 2017
Effect of genetic diagnosis on patients with previously undiagnosed … March 19, 2019
Comparing NICU teamwork and safety climate across two commonly used survey … November 30, 2016
A middle ground on public accountability. … April 12, 2014
To disclose or not to disclose radiologic errors: should "patient-first
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psnet.ahrq.gov/issue/reporting-medical-errors-improve-patient-safety-survey-physicians-teaching-hospitals
February 24, 2011 - Study
Reporting medical errors to improve patient safety: a survey of physicians … Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. … Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. … Related Resources From the Same Author(s)
Disclosing medical errors to patients … November 16, 2022
Direct reporting of laboratory test results to patients by mail to
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - of omission as they do on errors of commission. … January 22, 2017
Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety … culture in a surgical inpatient unit. … November 25, 2009
Transfers of patient care between house staff on internal medicine … wards: a national survey.
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psnet.ahrq.gov/issue/developing-high-performance-team-training-framework-internal-medicine-residents-abcs-teamwork
June 01, 2011 - September 11, 2013
Medication safety messages for patients via the web portal: the MedCheck … safety, learning environments, and relationships with continuity patients. … December 12, 2018
The effect of workload reduction on the quality of residents' discharge … Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey … February 18, 2011
Improving safety culture on adult medical units through multidisciplinary
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psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement
June 21, 2010 - March 30, 2022
Situation awareness and the mitigation of risk associated with patient … December 1, 2021
The relationship between patient safety culture and the intentions of … Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey … Do falls and other safety issues occur more often during handovers when nurses are away from patients … October 17, 2012
Influence of unit-level staffing on medication errors and falls in military
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psnet.ahrq.gov/issue/ashamed-admit-it-owning-medical-error
April 03, 2019 - February 28, 2024
National survey of patient safety experiences in hospital medicine … September 25, 2024
Drug-drug interactions and actual harm to hospitalized patients: a … April 10, 2024
The benefits and opportunities: engaging patients in identifying and reporting … patient safety incidents. … September 9, 2010
Disclosing medical errors to patients: a challenge for health care
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psnet.ahrq.gov/issue/error-traps-pediatric-patient-blood-management-perioperative-period
January 12, 2022 - Related Resources From the Same Author(s)
Evaluation of clinical practice guidelines on … March 14, 2022
Safety culture in cardiac surgical teams: data from five programs and … September 18, 2024
Multistate point-prevalence survey of health care-associated infections … Associations between national board exam performance and residency program emphasis on … September 11, 2019
View More
Related Resources
Perspectives on
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psnet.ahrq.gov/issue/patient-safety-what-about-patient
January 22, 2025 - authors emphasize that neither the patient’s role in preventing errors nor the impact of these errors on … patients and their families has been adequately addressed. … symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey … scale and nature of harm to patients in hospital. … December 5, 2018
Advising patients about patient safety: current initiatives risk shifting
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psnet.ahrq.gov/issue/system-errors-intrapartum-electronic-fetal-monitoring-case-review
May 16, 2012 - February 7, 2024
Effect of an emergency department process improvement package on suicide … October 10, 2018
Role-modeling and medical error disclosure: a national survey of trainees … June 25, 2010
Perceptions of safety culture vary across the intensive care units of a … A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on … September 29, 2010
Communication and teamwork in patient care: how much can we learn