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Saver C. OR Manager. 2016;32:22-26.
Achieving high reliability has attracted attention as a goal in health care. This article provides an overview of high reliability principles and highlights the need to address communication breakdowns and normalization of deviance in health care institutions to ensure improvement.
TeamSTEPPS Master Training Course.
Johns Hopkins Armstrong Institute for Patient Safety and Quality. June 25-26, 2019; Constellation Energy Building, Baltimore, MD.
Using incident reports to assess communication failures and patient outcomes.
Umberfield E, Ghaferi AA, Krein SL, Manojlovich M. Jt Comm J Qual Patient Saf. 2019 Mar 29; [Epub ahead of print].
Learning From Invited Reviews.
London, UK: Royal College of Surgeons of England; 2019.
Improving standardization of paging communication using quality improvement methodology.
Weigert RM, Schmitz AH, Soung PJ, Porada K, Weisgerber MC. Pediatrics. 2019;143:e20181362.
Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.
Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019 Mar 1; [Epub ahead of print].
Teamwork—Part 1: Divided We Fall; Part 2: Cursed By Knowledge—Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.
Rosenbaum L. N Engl J Med. 2019;380:684-688;786-790;881-885.
The path to diagnostic excellence includes feedback to calibrate how clinicians think.
Meyer AND, Singh H. JAMA. 2019;321:737-738.
The impact of mobile technology on teamwork and communication in hospitals: a systematic review.
Martin G, Khajuria A, Arora S, King D, Ashrafian H, Darzi A. J Am Med Inform Assoc. 2019;26:339-355.
Characterising ICU–ward handoffs at three academic medical centres: process and perceptions.
Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019 Jan 12; [Epub ahead of print].
Debriefing for Clinical Learning
Medicines-related harm in the elderly post-hospital discharge.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Overcoming human barriers to safety event reporting in radiology.
Siewert B, Brook OR, Swedeen S, Eisenberg RL, Hochman M. Radiographics. 2019;39:251-263.
Data omission by physician trainees on ICU rounds.
Artis KA, Bordley J, Mohan V, Gold JA. Crit Care Med. 2019;47:403-409.
The impact of computerised physician order entry and clinical decision support on pharmacist–physician communication in the hospital setting: a qualitative study.
Pontefract SK, Coleman JJ, Vallance HK, et al. PLoS One. 2018;13:e0207450.
A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and teamwork in maternity care.
Rönnerhag M, Severinsson E, Haruna M, Berggren I. J Adv Nurs. 2019;75:585-593.
Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial.
Oner C, Fisher N, Atallah F, et al. Simul Healthc. 2018;13:404-412.
Advancing patient safety through the clinical application of a framework focused on communication.
Manojlovich M, Hofer TP, Krein SL. J Patient Saf. 2018 Oct 31; [Epub ahead of print].
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Steelman VM, Thenuwara K, Shaw C, Shine L. Jt Comm J Qual Patient Saf. 2019;45:81-90.
Adverse events during dental care for children: implications for practitioner health and wellness.
Nainar SMH. Pediatr Dent. 2018;40:323-326.
How communications issues between doctors and nurses can affect your health.
Howley EK. US News & World Report. September 5, 2018.
Guideline implementation: team communication.
Link T. AORN J. 2018;108:165-177.
Critical role of the surgeon–anesthesiologist relationship for patient safety.
Cooper JB. Anesthesiology. 2018;129:402-405.
Redesigning rounds in the ICU: standardizing key elements improves interdisciplinary communication.
O'Brien A, O'Reilly K, Dechen T, et al. Jt Comm J Qual Patient Saf. 2018;44:590-598.
Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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