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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44324/psn-pdf
    September 09, 2015 - Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. September 9, 2015 Ashcroft DM, Lewis PJ, Tully MP, et al. Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospit…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38435/psn-pdf
    February 25, 2009 - Prescribing discrepancies likely to cause adverse drug events after patient transfer. February 25, 2009 Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009;18(1):32-6. doi:10.1136/qshc.2007.025957. https://psnet.ah…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40092/psn-pdf
    December 22, 2010 - The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure. December 22, 2010 Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure. Chest. 2010;138(6):14…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845357/psn-pdf
    March 29, 2023 - Reducing hospital harm: establishing a command centre to foster situational awareness. March 29, 2023 Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885. https://psnet.ahrq.gov/innovation/reducing-hospital-harm-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40166/psn-pdf
    April 03, 2017 - A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2. April 3, 2017 Scott C, Gerardi D. A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 1. Jt Comm J Qual Patient Saf. 2…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46471/psn-pdf
    March 20, 2018 - Diagnostic errors in primary care pediatrics: Project RedDE. March 20, 2018 Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds. 2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42788/psn-pdf
    January 19, 2014 - Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. January 19, 2014 Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544. https://psnet.ahrq.gov/issue…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39970/psn-pdf
    January 22, 2017 - Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. January 22, 2017 Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce central line-associated bloodstream infections. Jt Comm J Qual Patient Saf. 2010;36(11):525-8. htt…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37327/psn-pdf
    March 03, 2011 - Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. March 3, 2011 Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical pati…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38449/psn-pdf
    March 04, 2009 - A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. March 4, 2009 Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. Q…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45097/psn-pdf
    May 09, 2017 - Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. May 9, 2017 Qato DM, Wilder J, Schumm P, et al. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38628/psn-pdf
    May 13, 2009 - Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings. May 13, 2009 Ouchida K, LoFaso VM, Capello CF, et al. Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings. J Am Geriatr So…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43224/psn-pdf
    June 11, 2014 - Look alike/sound alike drugs: a literature review on causes and solutions. June 11, 2014 Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6. https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42819/psn-pdf
    October 31, 2014 - Implementing a national program to reduce catheter- associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. October 31, 2014 Fakih MG, George C, Edson B, et al. Implementing a national prog…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46667/psn-pdf
    February 22, 2018 - Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care. February 22, 2018 Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary car…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73252/psn-pdf
    January 01, 2022 - Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. May 12, 2021 Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73527/psn-pdf
    July 28, 2021 - Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. July 28, 2021 Geerts JM, Kinnair D, Taheri P, et al. Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. JAMA Netw Open. 2021;4(7):e2120295. doi:10.100…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38983/psn-pdf
    February 10, 2015 - Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. February 10, 2015 Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484. doi:10.1377/hlthaff.28.5.1475. https://psnet.ahrq.…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43723/psn-pdf
    October 03, 2017 - Shining a Light: Safer Health Care Through Transparency. October 3, 2017 Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015. https://psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency Health care has historically treated data as something to be safeguarded rat…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37613/psn-pdf
    March 12, 2008 - Implementing patient safety interventions in your hospital: what to try and what to avoid. March 12, 2008 Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007. https://psnet.a…

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