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psnet.ahrq.gov/node/47880/psn-pdf
June 18, 2019 - A multidisciplinary model for reviewing severe maternal
morbidity cases and teaching residents patient safety
principles.
June 18, 2019
Ogunyemi D, Hage N, Kim SK, et al. A Multidisciplinary Model for Reviewing Severe Maternal Morbidity
Cases and Teaching Residents Patient Safety Principles. Jt Comm J Qual Patient…
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psnet.ahrq.gov/node/851458/psn-pdf
July 19, 2023 - Improving handoffs in the perioperative environment: a
conceptual framework of key theories, system factors,
methods, and core interventions to ensure success.
July 19, 2023
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a
conceptual framework of key theories, syste…
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psnet.ahrq.gov/node/867446/psn-pdf
January 08, 2025 - Methodological approaches for analyzing medication
error reports in patient safety reporting systems: a
scoping review.
January 8, 2025
Tchijevitch O, Hansen SM-B, Hallas J, et al. Methodological approaches for analyzing medication error
reports in patient safety reporting systems: a scoping review. Jt Comm J Qual…
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psnet.ahrq.gov/node/867687/psn-pdf
March 05, 2025 - Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for
prospective hazard analysis.
March 5, 2025
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for prospe…
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psnet.ahrq.gov/node/72475/psn-pdf
November 18, 2020 - Omissions of care in nursing homes: a uniform definition
for research and quality improvement.
November 18, 2020
Mangrum R, Stewart MD, Gifford DR, et al. Omissions of care in nursing homes: a uniform definition for
research and quality improvement. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.
doi:10.1016/j.jamda…
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psnet.ahrq.gov/node/72661/psn-pdf
January 20, 2021 - An intervention to increase situational awareness and the
Culture of Mutual Care (Foco) and its effects during
COVID-19 pandemic: a randomized controlled trial and
qualitative analysis.
January 20, 2021
Kozasa EH, Lacerda SS, Polissici MA, et al. An Intervention to Increase Situational Awareness and the
Culture o…
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psnet.ahrq.gov/node/838019/psn-pdf
September 07, 2022 - Strength of safety measures introduced by medical
practices to prevent a recurrence of patient safety
incidents: an observational study.
September 7, 2022
Müller BS, Lüttel D, Schütze D, et al. Strength of safety measures introduced by medical practices to
prevent a recurrence of patient safety incidents: an obser…
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www.ahrq.gov/topics/patient-experience.html
Topic: Patient Experience
AHRQ's Consumer Assessment of Healthcare Providers and Systems program measures the patient experience, which includes several aspects of healthcare delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and goo…
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psnet.ahrq.gov/node/857445/psn-pdf
January 01, 2024 - The racial disparities in maternal mortality and impact of
structural racism and implicit racial bias on pregnant
Black women: a review of the literature.
December 6, 2023
Montalmant KE, Ettinger AK. The racial disparities in maternal mortality and impact of structural racism and
implicit racial bias on pregnant b…
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psnet.ahrq.gov/node/47902/psn-pdf
April 24, 2019 - Recommendations from a national panel on quality
improvement in obstetrics.
April 24, 2019
Lefebvre G, Calder LA, De Gorter R, et al. Recommendations From a National Panel on Quality
Improvement in Obstetrics. J Obstet Gynaecol Can. 2019;41(5):653-659. doi:10.1016/j.jogc.2019.02.011.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/851057/psn-pdf
June 28, 2023 - The burden of peri-operative work at night as perceived
by anaesthesiologists: an international survey.
June 28, 2023
Cortegiani A, Ippolito M, Lakbar I, et al. The burden of peri-operative work at night as perceived by
anaesthesiologists: an international survey. Eur J Anaesthesiol. 2023;40(5):326-333.
doi:10.109…
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psnet.ahrq.gov/node/48110/psn-pdf
August 14, 2019 - The courage to speak out: a study describing nurses'
attitudes to report unsafe practices in patient care.
August 14, 2019
Cole DA, Bersick E, Skarbek A, et al. The courage to speak out: A study describing nurses' attitudes to
report unsafe practices in patient care. J Nurs Manag. 2019;27(6):1176-1181. doi:10.1111/…
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psnet.ahrq.gov/node/34802/psn-pdf
January 01, 2016 - The Veterans Affairs root cause analysis system in action.
September 3, 2015
Bagian JP, Gosbee JW, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt
Comm J Qual Improv. 2016;28(10):531-545. doi:10.1016/s1070-3241(02)28057-8.
https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysi…
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psnet.ahrq.gov/node/43957/psn-pdf
June 21, 2015 - Enhancing the effectiveness of team debriefings in
medical simulation: more best practices.
June 21, 2015
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical
simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3):115-125.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60317/psn-pdf
May 13, 2020 - The nurse's experience of decision-making processes in
missed nursing care: a qualitative study.
May 13, 2020
Abdelhadi N, Drach?Zahavy A, Srulovici E. The nurse’s experience of decision?making processes in
missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-2170. doi:10.1111/jan.14387.
https://p…
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psnet.ahrq.gov/node/46101/psn-pdf
January 01, 2018 - Factors associated with barcode medication
administration technology that contribute to patient
safety: an integrative review.
December 19, 2017
Strudwick G, Reisdorfer E, Warnock C, et al. Factors Associated With Barcode Medication Administration
Technology That Contribute to Patient Safety: An Integrative Review…
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psnet.ahrq.gov/node/862155/psn-pdf
February 07, 2024 - Society of Critical Care Medicine Guidelines on
Recognizing and Responding to Clinical Deterioration
Outside the ICU: 2023.
February 7, 2024
Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine Guidelines on Recognizing and
Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care M…
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psnet.ahrq.gov/node/46121/psn-pdf
January 01, 2021 - Quality of handoffs in community pharmacies.
May 10, 2017
Abebe E, Stone JA, Lester CA, et al. Quality of Handoffs in Community Pharmacies. J Patient Saf.
2021;17(6):405-411. doi:10.1097/PTS.0000000000000382.
https://psnet.ahrq.gov/issue/quality-handoffs-community-pharmacies
Handoffs present a significant patient …
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psnet.ahrq.gov/node/44953/psn-pdf
March 09, 2016 - Patient safety room of horrors: a novel method to assess
medical students and entering residents' ability to identify
hazards of hospitalisation.
March 9, 2016
Farnan JM, Gaffney S, Poston JT, et al. Patient safety room of horrors: a novel method to assess medical
students and entering residents' ability to identi…
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psnet.ahrq.gov/node/46818/psn-pdf
April 18, 2018 - Barriers and facilitators to hospital pharmacists'
engagement in medication safety activities: a qualitative
study using the theoretical domains framework.
April 18, 2018
Mekonnen AB, McLachlan AJ, Brien J-AE, et al. Barriers and facilitators to hospital pharmacists'
engagement in medication safety activities: a q…