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Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
This AHRQ-funded Partnerships in Implementing Patient Safety (PIPS) project report presents an implementation structure for medication safety and safety culture development in small rural hospitals.
Healthcare 411: medication safety toolkit.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
The Nurse's Role in Promoting a Culture of Patient Safety.
Friesen MA, Farquhar MB, Hughes R. American Nurses Association (ANA) Continuing Education, Center for American Nurses; 2005.
Patient Safety Improvement Corps: An AHRQ/VA partnership.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
Patient Safety: Investigating and Reporting Serious Clinical Incidents.
Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
Hospital inpatients' experiences: percentage of parents who reported how often providers prevented mistakes and helped them to report concerns.
Rockville, MD: National Quality Measures Clearinghouse; December 2015.
How surgical trainees handle catastrophic errors: a qualitative study.
Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-1184.
Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence.
Dankoski ME, Bickel J, Gusic ME. Acad Med. 2014;89:1610-1613.
Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.
Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.
Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.
Kiersma ME, Darbishire PL, Plake KS, Oswald C, Walters BM. Am J Pharm Edu. 2009;73:article 99.
Promoting collaboration and transparency in patient safety.
Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.
Pump up the volume—tips for increasing error reporting.
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2006;11:1-2,4.
Learning and sharing safety lessons to improve patient care.
Woodward S. Nurs Stand. 2006;20:49-53.
What Every Health Care Organization Should Know about Sentinel Events.
McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.
An Agenda for Research in Ambulatory Patient Safety.
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
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.
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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