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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73429/psn-pdf
    June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36086/psn-pdf
    June 14, 2011 - Sensemaking of patient safety risks and hazards. June 14, 2011 Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards This commentary discusses the concept of …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41117/psn-pdf
    March 04, 2015 - The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. March 4, 2015 McKibbon A, Lokker C, Handler S, et al. The effectiveness of integrated health information technologies across the phases of medication man…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47758/psn-pdf
    April 17, 2019 - Contribution of adverse events to death of hospitalised patients. April 17, 2019 Haukland EC, Mevik K, von Plessen C, et al. Contribution of adverse events to death of hospitalised patients. BMJ Open Qual. 2019;8(1):e000377. doi:10.1136/bmjoq-2018-000377. https://psnet.ahrq.gov/issue/contribution-adverse-events-de…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35402/psn-pdf
    September 10, 2009 - Can patients be part of the solution? Views on their role in preventing medical errors. September 10, 2009 Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing medical errors. Med Care Res Rev. 2005;62(5):601-16. https://psnet.ahrq.gov/issue/can-patients-be…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45263/psn-pdf
    September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46278/psn-pdf
    July 19, 2017 - The opioid epidemic: what can surgeons do about it? July 19, 2017 Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18. https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45275/psn-pdf
    November 01, 2017 - Electronic tools to support medication reconciliation—a systematic review. November 1, 2017 Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068. https://psnet.ahrq.gov/issue/electronic-tools-s…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40097/psn-pdf
    January 19, 2011 - Use of an electronic information system to identify adverse events resulting in an emergency department visit. January 19, 2011 Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46025/psn-pdf
    July 11, 2017 - Measuring to improve medication reconciliation in a large subspecialty outpatient practice. July 11, 2017 Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223. doi:10.1016/j.jcjq.2017.02.005…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865974/psn-pdf
    May 29, 2024 - Minimizing bias when using artificial intelligence in critical care medicine. May 29, 2024 Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796. https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60227/psn-pdf
    April 15, 2020 - The next step in learning from sentinel events in healthcare. April 15, 2020 Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867049/psn-pdf
    October 30, 2024 - National Review of Maternity Services in England 2022 to 2024. October 30, 2024 National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality Commission; September 2024. https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024 Maternal safety is a gl…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40177/psn-pdf
    June 08, 2011 - Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. June 8, 2011 Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8. doi:1…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853233/psn-pdf
    September 06, 2023 - Weight estimation for drug dose calculations in the prehospital setting - a systematic review. September 6, 2023 Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027. htt…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46298/psn-pdf
    October 18, 2017 - CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy. October 18, 2017 Kuang C. Fast Company. October 4, 2017. https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy Complicated systems often require more than one change to improve their s…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44785/psn-pdf
    January 27, 2016 - Reducing Adverse Drug Events Related to Opioids Implementation Guide. January 27, 2016 Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015. https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide Opioids are high-risk medication…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46711/psn-pdf
    July 01, 2019 - The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse. July 1, 2019 Washington, DC: America's Health Insurance Plans; 2019. https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety- and-reduced-risk Gu…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47213/psn-pdf
    June 20, 2018 - Are second victims getting the help they need? June 20, 2018 Headley M. Patient Saf Qual Healthc. May/June 2018. https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building p…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38747/psn-pdf
    September 16, 2009 - Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture. September 16, 2009 Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide …

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