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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74838/psn-pdf
    February 16, 2022 - Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. February 16, 2022 Gunderson CG, Rodwin BA. Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement. J Hosp Med. 2022;17(5):399-402. doi:10.1002/jhm.2768.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72718/psn-pdf
    February 10, 2021 - Assessing reasons for decreased primary care access for individuals on prescribed opioids: an audit study. February 10, 2021 Lagisetty P, Macleod C, Thomas J, et al. Assessing reasons for decreased primary care access for individuals on prescribed opioids. Pain. 2021;162(5):1379-1386. doi:10.1097/j.pain.00000000000…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34085/psn-pdf
    February 09, 2011 - Discussion of medical errors in morbidity and mortality conferences. February 9, 2011 Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290(21):2838-2842. https://psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-confer…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45299/psn-pdf
    July 20, 2016 - Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. July 20, 2016 Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilitated Discharge Counseling and Medic…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38491/psn-pdf
    January 31, 2011 - Diagnostic errors--The next frontier for patient safety. January 31, 2011 Newman-Toker DE, Pronovost P. Diagnostic errors--the next frontier for patient safety. JAMA. 2009;301(10):1060-2. doi:10.1001/jama.2009.249. https://psnet.ahrq.gov/issue/diagnostic-errors-next-frontier-patient-safety Studies from autopsy dat…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36797/psn-pdf
    August 26, 2011 - The American College of Surgeons' closed claims study: new insights for improving care. August 26, 2011 Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons’ Closed Claims Study: New Insights for Improving Care. J Am Coll Surg. 2007;204(4). doi:10.1016/j.jamcollsurg.2007.01.013. https://p…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848820/psn-pdf
    May 10, 2023 - Error disclosure in neonatal intensive care: a multicentre, prospective, observational study. May 10, 2023 Passini L, Le Bouedec S, Dassieu G, et al. Error disclosure in neonatal intensive care: a multicentre, prospective, observational study. BMJ Qual Saf. 2023;32(10):589-599. doi:10.1136/bmjqs-2022-015247. https…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837632/psn-pdf
    July 06, 2022 - Serious experience events: applying patient safety concepts to improve patient experience. July 6, 2022 Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety concepts to improve patient experience. J Patient Exp. 2022;9:237437352211026. doi:10.1177/23743735221102670. …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43808/psn-pdf
    April 22, 2015 - Preventing iatrogenic overdose: a review of in–emergency department opioid-related adverse drug events and medication errors. April 22, 2015 Beaudoin FL, Merchant RC, Janicki A, et al. Preventing iatrogenic overdose: a review of in-emergency department opioid-related adverse drug events and medication errors. Ann …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35802/psn-pdf
    January 02, 2017 - Reconciliation failures lead to medication errors. January 2, 2017 Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors Medication reconciliation represents an active effort of hospita…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866313/psn-pdf
    July 17, 2024 - Towards understanding and improving medication safety for patients with mental illness in primary care: a multimethod study. July 17, 2024 Ayre MJ, Lewis PJ, Phipps DL, et al. Towards understanding and improving medication safety for patients with mental illness in primary care: a multimethod study. Health Expect.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72707/psn-pdf
    February 03, 2021 - Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. February 3, 2021 Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Eur J Hosp Pharm. 2021;28(Suppl 2):e151-e156. doi:10.1…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836807/psn-pdf
    March 30, 2022 - Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up. March 30, 2022 Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up. NEJM Catal Innov Care Deliv. 2022;3(4). https://p…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35403/psn-pdf
    February 18, 2011 - Mortality among patients admitted to hospitals on weekends as compared with weekdays. February 18, 2011 Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. New Engl J Med. 2001;345(9):663-668. https://psnet.ahrq.gov/issue/mortality-among-patients-admitted-h…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46423/psn-pdf
    December 16, 2017 - Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation. December 16, 2017 Wolf DA, Drake SA, Snow FK. Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation. Am J Forensic Med Pathol. 2017;38(4):294-297. doi…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73637/psn-pdf
    August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. August 25, 2021 Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197. https://psnet.ahrq.gov/issue/failures-care-coordination-and-re…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839826/psn-pdf
    November 09, 2022 - Professional behavior and value erosion: a qualitative study of physicians and the electronic health record. November 9, 2022 Skeff KM, Brown-Johnson CG, Asch SM, et al. Professional behavior and value erosion: a qualitative study of physicians and the electronic health record. J Healthc Manag. 2022;67(5):339-352. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861763/psn-pdf
    January 31, 2024 - The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis. January 31, 2024 Haylor H, Sparkes T, Armitage G, et al. The process and perspective of serious incident investigations in adult community mental health services: integrative …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38662/psn-pdf
    April 12, 2011 - Patient error: a preliminary taxonomy. April 12, 2011 Buetow S, Kiata L, Liew T, et al. Patient error: a preliminary taxonomy. Ann Fam Med. 2009;7(3):223-31. doi:10.1370/afm.941. https://psnet.ahrq.gov/issue/patient-error-preliminary-taxonomy Preliminary research has found that patient factors may contribute to er…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866518/psn-pdf
    January 01, 2025 - Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. August 14, 2024 Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. J Gen Intern Med. 2025;40(3):525-531. doi:10.1007/s11606-024-08950…