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psnet.ahrq.gov/node/41497/psn-pdf
April 05, 2013 - Avoiding handover fumbles: a controlled trial of a
structured handover tool versus traditional handover
methods.
April 5, 2013
Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover
tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…
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psnet.ahrq.gov/node/36975/psn-pdf
March 24, 2011 - Safety of telephone triage in general practitioner
cooperatives: do triage nurses correctly estimate
urgency?
March 24, 2011
Giesen P, Ferwerda R, Tijssen R, et al. Safety of telephone triage in general practitioner cooperatives: do
triage nurses correctly estimate urgency? Qual Saf Health Care. 2007;16(3):181-4.
…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-sops-teamstepps-webcast-sorra.pdf
January 01, 2010 - Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Sorra
Linking TeamSTEPPS and SOPS
TeamSTEPPS and SOPS Research
• Reviewed 14 articles in the
SOPS Bibliography that
used TeamSTEPPS training
and SOPS as an outcome to
assess patient safety culture
Countries
• 11 U.S. studies
• 3 …
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www.ahrq.gov/hai/cusp/toolkit/board-checklist.html
December 01, 2012 - Board Checklist
CUSP Toolkit
Who should use this tool? Senior leaders.
Checklist items
Leader Responsible
Date Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork climate using valid measures.
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/boardchecklist.doc
June 02, 2025 - Checklist Items
Leader Responsible
Date
Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork climate using valid measures.
3. Set expectation for unit-level culture assessment.
4. Require at least a 60 percent participation…
-
psnet.ahrq.gov/node/47303/psn-pdf
March 18, 2019 - Transforming concepts in patient safety: a progress
report.
March 18, 2019
Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ
Qual Saf. 2018;27(12):1019-1026. doi:10.1136/bmjqs-2017-007756.
https://psnet.ahrq.gov/issue/transforming-concepts-patient-safety-progress…
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psnet.ahrq.gov/node/45225/psn-pdf
June 15, 2016 - A case of transfusion error in a trauma patient with
subsequent root cause analysis leading to institutional
change.
June 15, 2016
Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root
cause analysis leading to institutional change. J Investig Med High Impact Case R…
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psnet.ahrq.gov/node/44558/psn-pdf
April 25, 2016 - Using voluntary reports from physicians to learn from
diagnostic errors in emergency medicine.
April 25, 2016
Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from
diagnostic errors in emergency medicine. Emerg Med J. 2016;33(4):245-252. doi:10.1136/emermed-2014-
204604.
…
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psnet.ahrq.gov/node/38142/psn-pdf
April 30, 2014 - Medical error disclosure among pediatricians: choosing
carefully what we might say to parents.
April 30, 2014
Loren DJ, Klein EJ, Garbutt J, et al. Medical Error Disclosure Among Pediatricians. Arch Pediatr Adolesc
Med. 2008;162(10):922-927. doi:10.1001/archpedi.162.10.922.
https://psnet.ahrq.gov/issue/medical-err…
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psnet.ahrq.gov/node/45907/psn-pdf
December 22, 2017 - Primary care collaboration to improve diagnosis and
screening for colorectal cancer.
December 22, 2017
Schiff G, Bearden T, Hunt LS, et al. Primary Care Collaboration to Improve Diagnosis and Screening for
Colorectal Cancer. Jt Comm J Qual Patient Saf. 2017;43(7):338-350. doi:10.1016/j.jcjq.2017.03.004.
https://ps…
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psnet.ahrq.gov/node/855429/psn-pdf
November 15, 2023 - Effect of complementary interventions to redesign care
on teamwork and quality for hospitalized medical
patients: a pragmatic controlled trial.
November 15, 2023
O’Leary KJ, Johnson JK, Williams MV, et al. Effect of complementary interventions to redesign care on
teamwork and quality for hospitalized medical patie…
-
psnet.ahrq.gov/node/44114/psn-pdf
September 27, 2016 - Advancing the future of patient safety in oncology:
implications of patient safety education on cancer care
delivery.
September 27, 2016
James TA, Goedde M, Bertsch T, et al. Advancing the Future of Patient Safety in Oncology: Implications of
Patient Safety Education on Cancer Care Delivery. J Cancer Educ. 2016;31…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/safford.pdf
December 17, 2014 - Using Comparative Effectiveness Reviews to Optimize Quality of Life for Persons with Diabetes and Chronic Pain
Research to Help Underserved Populations
Innovative Adaptation and Dissemination of AHRQ Comparative Effectiveness
Research Products
Using Comparative Effectiveness Reviews to Optimize Quality of Life fo…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/malone.pdf
September 29, 2013 - Innovative Diffusion of Comparative Effectiveness Research
Research to Help Underserved Populations
Innovative Adaptation and Dissemination of AHRQ Comparative Effectiveness
Research Products
Innovative Diffusion of Comparative Effectiveness Research
Description
The purpose of this study was to develop and…
-
psnet.ahrq.gov/node/43193/psn-pdf
June 17, 2014 - Risks in the implementation and use of smart pumps in a
pediatric intensive care unit: application of the failure
mode and effects analysis.
June 17, 2014
Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of
smart pumps in a pediatric intensive care unit: applicati…
-
psnet.ahrq.gov/node/867089/psn-pdf
November 06, 2024 - Focused team engagements to enhance interprofessional
collaboration and safety behaviors among novice nurses
and medical residents.
November 6, 2024
Manuel R, Barber A, Kern J, et al. Focused team engagements to enhance interprofessional collaboration
and safety behaviors among novice nurses and medical residents.…
-
psnet.ahrq.gov/node/36201/psn-pdf
July 10, 2008 - US and Canadian physicians' attitudes and experiences
regarding disclosing errors to patients.
July 10, 2008
Gallagher TH, Waterman AD, Garbutt J, et al. US and Canadian physicians' attitudes and experiences
regarding disclosing errors to patients. Arch Intern Med. 2006;166(15):1605-11.
https://psnet.ahrq.gov/issu…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/board-checklist.html
July 01, 2023 - Board Checklist
AHRQ Safety Program for Perinatal Care
Who should use this tool: Senior leaders
Checklist Items
Leader Responsible
Date Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork c…
-
www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex12.html
July 01, 2018 - Guide to Patient and Family Engagement
Exhibit 12. Involving Patients and Family Members at the Hospital Level
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussio…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/hand-hygiene/skills-answer-key.docx
March 01, 2017 - AHRQ Safety Program for
Long-Term Care: HAIs/CAUTI
Training Module 1—Skills Questions Answer Key
The How-To’s of Hand Hygiene
1. How long should you rub your hands with soap when you are hand washing?
a. At least 5 seconds
b. At least 15 seconds
c. At least 30 seconds
d. At least 60 seconds
2. How long should you …