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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50653/psn-pdf
    November 13, 2019 - A national patient safety curriculum in pediatric emergency medicine. November 13, 2019 Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533. https://psnet.ahrq.gov/issue/national-patien…
  6. 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…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50445/psn-pdf
    October 09, 2019 - A demonstration project on the impact of safety culture on infection control practices in hemodialysis October 9, 2019 Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection control practices in hemodialysis. Am J Infect Control. 2019;47(9):1122-1129. doi:10.1016/j…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60020/psn-pdf
    March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills performance improvement. March 4, 2020 Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880. https://psnet.ahrq.gov/issue/enotss-platform-s…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60764/psn-pdf
    August 05, 2020 - As coronavirus ravaged nursing homes, inspectors were not being tested. August 5, 2020 Dolan J, Mejia B. As coronavirus ravaged nursing homes, inspectors were not being tested. Los Angeles Times. 2020;July 24. https://psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested Worker s…
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74016/psn-pdf
    October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review. October 27, 2021 Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035. https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review Patien…
  13. 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 …
  14. 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…
  15. 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 …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45251/psn-pdf
    August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong? August 24, 2016 Kowalczyk L. Boston Globe. August 14, 2016. https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series o…
  17. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37120/psn-pdf
    March 24, 2011 - Patient safety culture in primary care: developing a theoretical framework for practical use. March 24, 2011 Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care. 2007;16(4):313-20. https://psnet.ahrq.gov/issue/patie…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74117/psn-pdf
    December 16, 2021 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals. November 24, 2021 Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021. https://psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals The release of the Workplace Safety supplemental items for…
  20. 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…

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