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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42387/psn-pdf
    December 30, 2014 - 'Bad apples': time to redefine as a type of systems problem? December 30, 2014 Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138. https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem While …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866934/psn-pdf
    October 09, 2024 - How America’s health care system fails women in pain. October 9, 2024 Neklason A. How America’s health care system fails women in pain. The Hill. September 23, 2024; https://psnet.ahrq.gov/issue/how-americas-health-care-system-fails-women-pain Appropriate treatment of pain is a complicated process vulnerable to rac…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46332/psn-pdf
    September 24, 2017 - Sharing the process of diagnostic decision making. September 24, 2017 Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med. 2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929. https://psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making Improving diagnosis has …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38846/psn-pdf
    August 05, 2009 - Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures. August 5, 2009 Landro L. https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform- unregulated-outpatient This article discusses growing legal oversight on outpatient surg…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38405/psn-pdf
    February 11, 2009 - Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. February 11, 2009 Schnall R, Stone PW, Currie L, et al. Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. J Nurs Scholarsh. 2008;40(4):391-4. doi:10.1111/j.1547- 506…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38592/psn-pdf
    April 29, 2009 - The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. April 29, 2009 Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual Saf Health Care. 2009;18(2):137-40. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35982/psn-pdf
    September 17, 2010 - Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS). September 17, 2010 Varricchio F, Reed J, Group VAERSW. Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS). South Med J. 2006;99(5):486-9. https://psnet.ahrq.gov/issu…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60671/psn-pdf
    July 08, 2020 - Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. July 8, 2020 Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/nejmms2004740. https://psnet.ahrq.gov/issue…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40861/psn-pdf
    October 19, 2011 - Registered nurses' judgments of the classification and risk level of patient care errors. October 19, 2011 Chipps E, Wills CE, Tanda R, et al. Registered nurses' judgments of the classification and risk level of patient care errors. J Nurs Care Qual. 2011;26(4):302-310. doi:10.1097/NCQ.0b013e31820f4c57. https://ps…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836870/psn-pdf
    April 26, 2022 - A Conversation Among Stakeholders on Medical Malpractice. April 6, 2022 Collaborative for Accountability and Improvement. April 26, 2022. https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice Communication and resolution programs (CRP) can improve response to patients and families a…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851658/psn-pdf
    July 26, 2023 - The spectrum of hospitalization-associated harm in the elderly. July 26, 2023 Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med. 2023;115(Sept):29-33. doi:10.1016/j.ejim.2023.05.025. https://psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly Older pat…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45931/psn-pdf
    July 05, 2017 - The CARE approach to reducing diagnostic errors. July 5, 2017 Rush JL, Helms SE, Mostow EN. The CARE approach to reducing diagnostic errors. Int J Dermatol. 2017;56(6):669-673. doi:10.1111/ijd.13532. https://psnet.ahrq.gov/issue/care-approach-reducing-diagnostic-errors Cognitive aids such as checklists and mnemoni…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37881/psn-pdf
    July 02, 2008 - Simulated laparoscopic operating room crisis: an approach to enhance the surgical team performance. July 2, 2008 Powers KA, Rehrig ST, Irias N, et al. Simulated laparoscopic operating room crisis: An approach to enhance the surgical team performance. Surg Endosc. 2008;22(4):885-900. https://psnet.ahrq.gov/issue/si…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34788/psn-pdf
    March 28, 2005 - Cost of medication-related problems at a university hospital. March 28, 2005 Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital This study used retrospective chart review to determine estimated costs of defined medication-related …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42057/psn-pdf
    February 20, 2013 - Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. February 20, 2013 Sevdalis N, Hull L, Birnbach DJ. Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for acc…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36075/psn-pdf
    September 28, 2010 - Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems. September 28, 2010 Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoas…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60727/psn-pdf
    July 29, 2020 - A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020 Bhasin S, Gill TM, Reuben DB, et al. A randomized trial of a multifactorial strategy to prevent serious fall injuries. N Engl J Med. 2020;383(2):129-140. doi:10.1056/nejmoa2002183. https://psnet.ahrq.gov/issue/randomize…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45169/psn-pdf
    June 08, 2016 - High Reliability in Health Care. June 8, 2016 Joint Commission Center for Transforming Healthcare. https://psnet.ahrq.gov/issue/high-reliability-health-care Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867531/psn-pdf
    January 15, 2025 - Psychological Safety in Healthcare Settings. January 15, 2025 Psychological Safety in Healthcare Settings. Int J Public Health. 2024;69. https://psnet.ahrq.gov/issue/psychological-safety-healthcare-settings The importance of creating healthcare environments that enable concerns to be voiced and support individuals…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42943/psn-pdf
    April 12, 2014 - Doing right by our patients when things go wrong in the ambulatory setting. April 12, 2014 Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96. https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…

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