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psnet.ahrq.gov/node/42200/psn-pdf
December 18, 2013 - The relationship between patients' perceptions of team
effectiveness and their care experience in the emergency
department.
December 18, 2013
Kipnis A, Rhodes K, Burchill CN, et al. The relationship between patients' perceptions of team effectiveness
and their care experience in the emergency department. J Emerg M…
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psnet.ahrq.gov/node/46417/psn-pdf
October 11, 2017 - Center for Health Care Human Factors.
October 11, 2017
Armstrong Institute for Patient Safety and Quality.
https://psnet.ahrq.gov/issue/center-health-care-human-factors
Human factors engineering has provided unique insights into designing solutions to address human error
and system weaknesses that facilitate mista…
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psnet.ahrq.gov/node/45788/psn-pdf
March 01, 2017 - Latest Results From the "FIRST" Trial.
March 1, 2017
J Am Coll Surg. 2017;224:103-159.
https://psnet.ahrq.gov/issue/latest-results-first-trial
The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial examined residency program
response to duty hour rules. This special issue features studies ex…
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psnet.ahrq.gov/node/72801/psn-pdf
March 03, 2021 - Teamwork in the time of COVID-19.
March 3, 2021
Takizawa PA, Honan L, Brissette D, et al. Teamwork in the time of COVID?19. FASEB Bioadv.
2020;3(3):175-181. doi:10.1096/fba.2020-00093.
https://psnet.ahrq.gov/issue/teamwork-time-covid-19
The COVID-19 pandemic has led to wide-ranging changes in the health care syste…
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psnet.ahrq.gov/node/47321/psn-pdf
June 19, 2019 - Validation of a mobile app for reducing errors of
administration of medications in an emergency.
June 19, 2019
Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of
medications in an emergency. J Clin Monit Comput. . 2019;33(3):531-539. doi:10.1007/s10877-018-018…
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psnet.ahrq.gov/node/37555/psn-pdf
February 14, 2018 - ACOG Committee Opinion #730: fatigue and patient
safety.
February 14, 2018
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2018;131(2):e78-
e81.
https://psnet.ahrq.gov/issue/acog-committee-opinion-730-fatigue-and-patient-safety
This commentary discusses how sleep deprivation affects…
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psnet.ahrq.gov/node/764408/psn-pdf
March 02, 2022 - Ensuring critical instruments and devices are appropriate
for reuse.
March 2, 2022
Quick Safety. February 14, 2022;(64):1-3.
https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …
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psnet.ahrq.gov/node/849338/psn-pdf
May 24, 2023 - The impact of language barriers on patient care: a
pharmacy perspective.
May 24, 2023
Patel J. PM Healthcare Journal. Spring 2023(4):5-18.
https://psnet.ahrq.gov/issue/impact-language-barriers-patient-care-pharmacy-perspective
Language discordance is known to degrade medication safety. The article discusses an exa…
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psnet.ahrq.gov/node/47435/psn-pdf
November 07, 2018 - Cognitive bias in clinical medicine.
November 7, 2018
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-
232. doi:10.4997/JRCPE.2018.306.
https://psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
Cognitive biases can lead to unnecessary treatment and de…
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psnet.ahrq.gov/node/36946/psn-pdf
September 09, 2011 - The Patient Safety Leadership Academy at the University
of Pennsylvania: the first cohort's learning experience.
September 9, 2011
Wurster AB, Pearson K, Sonnad SS, et al. The Patient Safety Leadership Academy at the University of
Pennsylvania: the first cohort's learning experience. Qual Manag Health Care. 2007;16…
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psnet.ahrq.gov/node/42207/psn-pdf
April 24, 2013 - Patient safety and quality improvement education: a
cross-sectional study of medical students' preferences
and attitudes.
April 24, 2013
Teigland CL, Blasiak RC, Wilson LA, et al. Patient safety and quality improvement education: a cross-
sectional study of medical students' preferences and attitudes. BMC Med Educ…
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psnet.ahrq.gov/node/42500/psn-pdf
August 14, 2013 - When should students learn about ethics,
professionalism and patient safety?
August 14, 2013
Walton M, Jeffery H, Van Staalduinen S, et al. When should students learn about ethics, professionalism
and patient safety? Clin Teach. 2013;10(4):224-9. doi:10.1111/tct.12029.
https://psnet.ahrq.gov/issue/when-should-stud…
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psnet.ahrq.gov/node/38613/psn-pdf
May 20, 2009 - Improved operating room teamwork via SAFETY prep: a
rural community hospital's experience.
May 20, 2009
Paige JT, Aaron DL, Yang T, et al. Improved operating room teamwork via SAFETY prep: a rural
community hospital's experience. World J Surg. 2009;33(6):1181-7. doi:10.1007/s00268-009-9952-2.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46305/psn-pdf
September 27, 2017 - Using simulation to improve systems.
September 27, 2017
Kearney JA, Deutsch ES. Using Simulation to Improve Systems. Otolaryngol Clin North Am.
2017;50(5):1015-1028. doi:10.1016/j.otc.2017.05.011.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems-0
Simulations in health care can help uncover technical …
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psnet.ahrq.gov/node/44312/psn-pdf
November 06, 2015 - Beyond the team: understanding interprofessional work
in two North American ICUs.
November 6, 2015
Alexanian JA, Kitto S, Rak KJ, et al. Beyond the Team: Understanding Interprofessional Work in Two North
American ICUs. Crit Care Med. 2015;43(9):1880-6. doi:10.1097/CCM.0000000000001136.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60565/psn-pdf
June 03, 2020 - The public has been forgiving. But hospitals got some
things wrong.
June 3, 2020
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May
21.
https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
The complexity of the COVID-19 crisis cr…
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psnet.ahrq.gov/node/42702/psn-pdf
January 09, 2014 - Developing a quality and safety curriculum for fellows:
lessons learned from a neonatology fellowship program.
January 9, 2014
Gupta M, Ringer S, Tess A, et al. Developing a quality and safety curriculum for fellows: lessons learned
from a neonatology fellowship program. Acad Pediatr. 2014;14(1):47-53. doi:10.1016/…
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psnet.ahrq.gov/node/47005/psn-pdf
June 13, 2018 - "No-go considerations" for in situ simulation safety.
June 13, 2018
Bajaj K, Minors A, Walker K, et al. "No-Go Considerations" for In Situ Simulation Safety. Simul Healthc.
2018;13(3):221-224. doi:10.1097/SIH.0000000000000301.
https://psnet.ahrq.gov/issue/no-go-considerations-situ-simulation-safety
Frontline simul…
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psnet.ahrq.gov/node/41279/psn-pdf
September 19, 2016 - Medical error, incident investigation and the second
victim: doing better but feeling worse?
September 19, 2016
Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but
feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-2011-000605.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/40487/psn-pdf
June 01, 2011 - Developing and testing a tool to measure nurse/physician
communication in the intensive care unit.
June 1, 2011
Carbo AR, Tess AV, Roy CL, et al. Developing a High-Performance Team Training Framework for Internal
Medicine Residents. J Patient Saf. 2011;7(2). doi:10.1097/pts.0b013e31820dbe02.
https://psnet.ahrq.gov…