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3421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45520/psn-pdf
      October 05, 2016 - Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. October 5, 2016 Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994. http…

3422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45592/psn-pdf
      October 27, 2016 - Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. October 27, 2016 Chicago, IL: Health Research & Educational Trust; October 2016. https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center- transforming-hea…

3423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60007/psn-pdf
      March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. March 4, 2020 Horsham, PA: Institute for Safe Medication Practices; 2020. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion- pumps Smart pumps are widely available as a medicat…

3424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45609/psn-pdf
      November 16, 2016 - A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. November 16, 2016 Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000000536. https://psnet.ahrq.gov/…

3425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45249/psn-pdf
      June 22, 2016 - PHSO Review: Quality of NHS Complaints Investigations. June 22, 2016 First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94. https://psnet.ahrq.gov/issue/phso-review-quality-nhs-comp…

3426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37883/psn-pdf
      July 02, 2008 - The limits of knowledge management for UK public services modernization: the case of patient safety and service quality. July 2, 2008 Currie G, Waring J, Finn R. THE LIMITS OF KNOWLEDGE MANAGEMENT FOR UK PUBLIC SERVICES MODERNIZATION: THE CASE OF PATIENT SAFETY AND SERVICE QUALITY. Public Adm. 2008;86(2). doi:10.…

3427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45001/psn-pdf
      June 01, 2016 - Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units. June 1, 2016 Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical care units. Intensive Crit Care Nurs…

3428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45298/psn-pdf
      April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417- 422. doi:10.1136/bmjqs-2016-005511. https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to investigate incident…

3429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44821/psn-pdf
      December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. December 5, 2022 Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011. https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture Im…

3430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48022/psn-pdf
      May 29, 2019 - Inappropriate opioid prescription after surgery. May 29, 2019 Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet. 2019;393(10180):1547-1557. doi:10.1016/S0140-6736(19)30428-3. https://psnet.ahrq.gov/issue/inappropriate-opioid-prescription-after-surgery The overprescribing of o…

3431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48189/psn-pdf
      August 14, 2019 - Professionalism lapses and adverse childhood experiences: reflections from the island of last resort. August 14, 2019 Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/ACM.0000000000002793. https://psnet.ah…

3432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44231/psn-pdf
      January 22, 2016 - Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety. January 22, 2016 Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-9. doi:10.1097/NCQ.0000000000000131.…

3433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46482/psn-pdf
      October 11, 2017 - What can physicians do to help curb the opioid crisis? October 11, 2017 Bendix J. https://psnet.ahrq.gov/issue/what-can-physicians-do-help-curb-opioid-crisis The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article…

3434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46741/psn-pdf
      June 07, 2018 - Suffering in silence: medical error and its impact on health care providers. June 7, 2018 Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001. https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…

3435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60363/psn-pdf
      March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex- postdischarge-needs Summary Under a program kn…

3436. When the Meds Don’t Reach the Bed | PSNet
      psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
      May 16, 2022 - When the Meds Don’t Reach the Bed Citation Text: Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

3437. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - The review notes that addressing these power imbalances is an important path forward for truly successful

3438. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - The review notes that addressing these power imbalances is an important path forward for truly successful

3439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34980/psn-pdf
      February 15, 2011 - Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. February 15, 2011 Akins RB, Cole BR. J Patient Saf. 2005;1(1):9-16. https://psnet.ahrq.gov/issue/barriers-implementation-patient-safety-systems-healthcare-institutions- leadership-and-policy In or…

3440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867533/psn-pdf
      January 15, 2025 - AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding. January 15, 2025 AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding. Agency for Healthcare Quality and Research. Special Emphasis Notice.…