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4741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36542/psn-pdf
      August 06, 2008 - Pediatric rapid response teams in the academic medical center. August 6, 2008 Mistry KP, Turi J, Hueckel RM, et al. Pediatric Rapid Response Teams in the Academic Medical Center. Clin Pediatr Emerg Med. 2006;7(4). doi:10.1016/j.cpem.2006.08.010. https://psnet.ahrq.gov/issue/pediatric-rapid-response-teams-academic-…

4742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836791/psn-pdf
      August 21, 2024 - TeamSTEPPS for Diagnosis Improvement. August 21, 2024 TeamSTEPPS for Diagnosis Improvement. https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new Te…

4743. Not-So-Therapeutic Tap | PSNet
      psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
      December 01, 2014 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Assessing

4744. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43682/psn-pdf
      November 19, 2014 - Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. November 19, 2014 Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593. https://psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis Articles in this special issue discuss common pitfalls in musculoskeletal imaging that can con…

4745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73326/psn-pdf
      June 01, 2021 - CANDOR Webinar Series. June 1, 2021 Patient Safety Movement Foundation. 2021.  https://psnet.ahrq.gov/issue/candor-webinar-series The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webi…

4746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36425/psn-pdf
      December 22, 2010 - Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. December 22, 2010 Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med. 2006;130(11):1662-1668. https://p…

4747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74095/psn-pdf
      February 01, 2022 - Zero Suicide Initiative. November 17, 2021 Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893. https://psnet.ahrq.gov/issue/zero-suicide-initiative Patient suicide attempts are considered never events. This funding announcement calls for pr…

4748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43560/psn-pdf
      September 24, 2014 - Burnout in Healthcare. September 24, 2014 Laschinger H, Montgomery A, eds. Burnout Res. 2014;1:57-102. https://psnet.ahrq.gov/issue/burnout-healthcare Burnout has been linked to depression, work dissatisfaction, and increased rates of adverse events. Articles in this special issue explore health professionals' exp…

4749. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47354/psn-pdf
      November 21, 2018 - Improving Diagnosis in Medicine Change Package. November 21, 2018 Chicago, IL: Health Research & Educational Trust; 2018. https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides …

4750. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45442/psn-pdf
      October 12, 2016 - Radiotherapy Incident Reporting and Analysis System. October 12, 2016 Center for Assessment of Radiological Sciences. 4913 Wuakesha Street, Madison,WI 53705. 608-345- 5795. Email: brthomad@cars-pso.org. https://psnet.ahrq.gov/issue/radiotherapy-incident-reporting-and-analysis-system Patient Safety Organizations en…

4751. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36622/psn-pdf
      January 14, 2011 - Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. January 14, 2011 Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. Am J Clin Pathol. 2007;127(1):144-52. https://psnet.ahrq.gov/issue/measu…

4752. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43375/psn-pdf
      July 23, 2014 - Managing risk at the point-of-care: preventing errors. July 23, 2014 Njoroge S; Nichols JH. https://psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action and laboratory staff performing the analys…

4753. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73451/psn-pdf
      June 30, 2021 - National Patient Safety Syllabus. June 30, 2021 Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021. https://psnet.ahrq.gov/issue/national-patient-safety-syllabus Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a challenge. This st…

4754. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37086/psn-pdf
      October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. October 3, 2011 Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…

4755. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34719/psn-pdf
      December 23, 2008 - Learning from samples of one or fewer. December 23, 2008 March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465- 472.) https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer Organizations learn from experience. However, learning from rare events is challenging becau…

4756. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35111/psn-pdf
      April 06, 2011 - Patient safety features of clinical computer systems: questionnaire survey of GP views. April 6, 2011 Morris CJ, Savelyich BSP, Avery A, et al. Patient safety features of clinical computer systems: questionnaire survey of GP views. Qual Saf Health Care. 2005;14(3):164-8. https://psnet.ahrq.gov/issue/patient-safety…

4757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34887/psn-pdf
      February 26, 2009 - Has the Leapfrog Group had an impact on the health care market? February 26, 2009 Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood). 2005;24(1):228-33. https://psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market The Le…

4758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836867/psn-pdf
      April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…

4759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866357/psn-pdf
      July 24, 2024 - People’s Experiences of Diagnosis. July 24, 2024 People’s Experiences Of Diagnosis. London, England: National Voices; June 2024. https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnosti…

4760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37564/psn-pdf
      June 12, 2008 - The medical emergency team system: a two hospital comparison. June 12, 2008 Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison. Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016. https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…