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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38923/psn-pdf
    September 09, 2009 - Improving communication in the emergency department. September 9, 2009 Redfern E, Brown R, Vincent C. Improving communication in the emergency department. Emerg Med J. 2009;26(9):658-61. doi:10.1136/emj.2008.065623. https://psnet.ahrq.gov/issue/improving-communication-emergency-department Implementation of structu…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41492/psn-pdf
    June 27, 2018 - Alarm fatigue hazards: the sirens are calling. June 27, 2018 Welch J. https://psnet.ahrq.gov/issue/alarm-fatigue-hazards-sirens-are-calling This article reports on alarm fatigue in clinical care, including the risks associated with it, and describes tactics to help reduce nuisance alarms. https://psnet.ahrq.gov/i…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37016/psn-pdf
    September 15, 2011 - Postoperative complications due to a retained surgical sponge. September 15, 2011 Sarda AK, Pandey D, Neogi S, et al. Postoperative complications due to a retained surgical sponge. Singapore Med J. 2007;48(6):e160-4. https://psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge The authors…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36953/psn-pdf
    June 13, 2007 - Quality and Safety Education for Nurses. June 13, 2007 Cronenwett L, ed. Nurs Outlook. 2007;55(3):117-162. https://psnet.ahrq.gov/issue/quality-and-safety-education-nurses This issue covers a variety of topics related to quality and safety education for nurses, including the integration of safety content into dail…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42508/psn-pdf
    December 18, 2017 - Watson: Beyond Jeopardy! December 18, 2017 Ferrucci D, Levas A, Bagchi S, et al. Watson: Beyond Jeopardy!. Artif Intell. 2012;199-200. doi:10.1016/j.artint.2012.06.009. https://psnet.ahrq.gov/issue/watson-beyond-jeopardy This commentary describes how question answering systems can augment evidence-based decision …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41736/psn-pdf
    September 02, 2016 - Drug shortages and clinicians: no time for complacency. September 2, 2016 Rochon P, Gurwitz JH. Drug shortages and clinicians: no time for complacency. Arch Intern Med. 2012;172(19):1499-500. https://psnet.ahrq.gov/issue/drug-shortages-and-clinicians-no-time-complacency This article comments on the patient safety …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35333/psn-pdf
    July 14, 2009 - Medication errors and drug-dispensing systems in a hospital pharmacy. July 14, 2009 Anacleto TA, Perini E, Rosa MB, et al. Medication errors and drug-dispensing systems in a hospital pharmacy. Clinics. 2006;60(4). doi:10.1590/s1807-59322005000400011. https://psnet.ahrq.gov/issue/medication-errors-and-drug-dispensi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39159/psn-pdf
    May 04, 2010 - Radiologists' responses to inadequate referrals. May 4, 2010 Lysdahl KB, Hofmann BM, Espeland A. Radiologists' responses to inadequate referrals. Eur Radiol. 2010;20(5):1227-33. doi:10.1007/s00330-009-1640-y. https://psnet.ahrq.gov/issue/radiologists-responses-inadequate-referrals Radiologists frequently receive i…
  9. psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
    October 14, 2020 - Study Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study. Citation Text: Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
  10. psnet.ahrq.gov/issue/diagnostic-uncertainty-among-critically-ill-children-admitted-picu-multicenter-study
    June 14, 2023 - Study Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. Citation Text: Cifra CL, Custer JW, Smith CM, et al. Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. Crit Care Med. 2025;53(2):e294-e307. …
  11. psnet.ahrq.gov/issue/burden-and-risk-factors-adverse-drug-events-older-patients-prospective-cross-sectional-study
    May 20, 2020 - Study The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. Citation Text: Tipping B, Kalula S, Badri M. The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. S Afr Med J. 2006;9…
  12. psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm
    March 23, 2022 - Study Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. Citation Text: Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…
  13. psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events
    November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…
  14. psnet.ahrq.gov/issue/cluster-randomized-trial-two-implementation-strategies-deliver-audit-and-feedback-equipped
    September 01, 2018 - Study A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. Citation Text: Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…
  15. psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
    January 17, 2012 - Study Classic Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…
  16. psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
    December 08, 2021 - Study Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality. Citation Text: Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…
  17. psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
    July 14, 2021 - Commentary Classic The new recommendations on duty hours from the ACGME Task Force. Citation Text: Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800. Copy…
  18. psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review
    March 23, 2012 - Review Classic Failure to follow-up test results for ambulatory patients: a systematic review. Citation Text: Callen JL, Westbrook JI, Georgiou A, et al. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. J Gen Intern Med. 2011;27(10…
  19. psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
    September 19, 2016 - Study Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. Citation Text: Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…
  20. psnet.ahrq.gov/issue/outcomes-associated-nationwide-introduction-rapid-response-systems-netherlands
    January 18, 2013 - Study Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands. Citation Text: Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …

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