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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43970/psn-pdf
    May 19, 2015 - Organisational reporting and learning systems: innovating inside and outside of the box. May 19, 2015 Sujan M, Furniss D. Organisational reporting and learning systems: Innovating inside and outside of the box. Clin Risk. 2015;21(1):7-12. doi:10.1177/1356262215574203. https://psnet.ahrq.gov/issue/organisational-re…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35990/psn-pdf
    September 17, 2010 - Misunderstanding of prescription drug warning labels among patients with low literacy. September 17, 2010 Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55. https://psnet.ahrq.gov/issue/misundersta…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45634/psn-pdf
    January 11, 2017 - Operating room traffic as a modifiable risk factor for surgical site infection. January 11, 2017 Wanta BT, Glasgow AE, Habermann EB, et al. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. Surg Infect (Larchmt). 2016;17(6):755-760. https://psnet.ahrq.gov/issue/operating-room-traffic-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34812/psn-pdf
    March 05, 2008 - The critical incident technique. March 5, 2008 FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358. https://psnet.ahrq.gov/issue/critical-incident-technique This review details the background of a methodology aimed to record specific behaviors, rather than opinions or estimates, in evalu…
  5. psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    May 29, 2024 - Getting the Diagnosis Both Right and Wrong Citation Text: Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  6. psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47002/psn-pdf
    April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). April 25, 2018 Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750. https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care- facilities-r18 Research …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45868/psn-pdf
    January 31, 2018 - Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events. January 31, 2018 Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee- Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906. doi:10.1016/j.acap.2017.01.00…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50863/psn-pdf
    February 05, 2020 - Patient safety in inpatient mental health settings: a systematic review. February 5, 2020 Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic review. BMJ Open. 2019;9(12):e030230. doi:10.1136/bmjopen-2019-030230. https://psnet.ahrq.gov/issue/patient-safety-inpat…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73483/psn-pdf
    July 14, 2021 - Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. July 14, 2021 Melnyk BM, Tan A, Hsieh AP, et al. Critical Care Nurses’ Physical and Mental Health, Worksite Wellness Support, and Medical Errors. Am J Crit Care. 2021;30(3):176-184. doi:10.4037/ajcc2021301. https://psn…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848817/psn-pdf
    May 10, 2023 - Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes. May 10, 2023 Hessels AJ, Guo J, Johnson CT, et al. Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes. Am J Infect Control. 2023;51(5):482-489. d…
  12. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866191/psn-pdf
    June 26, 2024 - Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook". June 26, 2024 Sullivan JL, Shin MH, Chan J, et al. Quality improvement lessons learned from National Implementation of the “Patient Safety Events …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34907/psn-pdf
    August 03, 2009 - Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter? August 3, 2009 Rosen AB, Blendon RJ, DesRoches CM, et al. Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter? Acad Med. 2005;80(2):189-92. https://psnet.ahrq.gov/issue…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45879/psn-pdf
    July 02, 2017 - A hybrid methodology for modeling risk of adverse events in complex health-care settings. July 2, 2017 Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702. https://psnet.ahrq.gov/issue/hybrid-m…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35028/psn-pdf
    May 27, 2011 - Medication errors and adverse drug events in pediatric inpatients. May 27, 2011 Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20. https://psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients This p…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38157/psn-pdf
    October 22, 2008 - Contributing factors identified by hospital incident report narratives. October 22, 2008 Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. https://psnet.ahrq.gov/issue/contributing-f…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44948/psn-pdf
    February 14, 2017 - Safer Healthcare: Strategies for the Real World. February 14, 2017 Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016 https://psnet.ahrq.gov/issue/safer-healthcare-strategies-real-world Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available for free dow…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42503/psn-pdf
    September 18, 2013 - The patient is in: patient involvement strategies for diagnostic error mitigation. September 18, 2013 McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-001623. https://psnet.ahrq.gov/i…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44804/psn-pdf
    November 18, 2016 - The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems. November 18, 2016 Flynn LC, McCulloch P, Morgan LJ, et al. The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effective…

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