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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47503/psn-pdf
    October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs. October 24, 2018 Peeples L. Pharmacy Practice News. October 10, 2018. https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs Structured handoffs can reduce communication problems that contribute to medical error. This magazine article re…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45841/psn-pdf
    March 01, 2017 - Monitoring the anaesthetist in the operating theatre—professional competence and patient safety. March 1, 2017 Larsson J. Monitoring the anaesthetist in the operating theatre - professional competence and patient safety. Anaesthesia. 2017;72 Suppl 1:76-83. doi:10.1111/anae.13743. https://psnet.ahrq.gov/issue/monit…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47979/psn-pdf
    May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists to improve diagnosis. May 1, 2019 Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829. https://psnet.ahrq.gov/iss…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60286/psn-pdf
    April 29, 2020 - With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications. April 29, 2020 Brodwin E. STAT. April 14, 2020. https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew- complications Patients with cancer and other chronic disorder treatment …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37444/psn-pdf
    January 02, 2008 - My brother's keeper: must a physician disclose another's medical error and potential negligence? January 2, 2008 Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10.1016/j.jclinane.2007.05.005. https://p…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43585/psn-pdf
    July 16, 2015 - At risk care plans: a way to reduce readmissions and adverse events. July 16, 2015 Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106. https://psnet.ahrq.gov/issue/risk-care-plans-way-reduc…
  7. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/checklist-creating.html
    May 01, 2017 - Checklist for Creating an Observation Tool - Coaching Clinical Teams Module This checklist can help you in each step of creating your observation tool. Development (Before Drafting Your Tool) → Drafting (Before Testing Your Tool) → Testing (Before Using Your Tool) …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45993/psn-pdf
    January 01, 2021 - 30-day potentially avoidable readmissions due to adverse drug events. May 3, 2017 Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346. https://psnet.ahrq.gov/issue/30-day-potentially-a…
  9. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
    March 01, 2017 - Learn From Defects AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety Who should use this tool? Senior l…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44118/psn-pdf
    May 19, 2018 - Inadequate preoperative team briefings lead to more intraoperative adverse events. May 19, 2018 Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181. https://psnet.ahrq.gov/issue/inadequate-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43149/psn-pdf
    July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. July 23, 2014 Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014. https://psnet.ahrq.gov/issue…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836726/psn-pdf
    March 09, 2022 - OpenNotes and patient safety: a perilous voyage into uncharted waters. March 9, 2022 Schust G, Manning M, Weil A. OpenNotes and patient safety: a perilous voyage into uncharted waters. J Gen Intern Med. 2022;37(8):2074-2076. doi:10.1007/s11606-021-07384-2. https://psnet.ahrq.gov/issue/opennotes-and-patient-safety-…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37737/psn-pdf
    January 06, 2017 - Can patient safety be measured by surveys of patient experiences? January 6, 2017 Solberg LI, Asche SE, Averbeck BM, et al. Can patient safety be measured by surveys of patient experiences? Jt Comm J Qual Patient Saf. 2008;34(5):266-274. https://psnet.ahrq.gov/issue/can-patient-safety-be-measured-surveys-patient-e…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45713/psn-pdf
    November 22, 2017 - Assigning responsibility to close the loop on radiology test results. November 22, 2017 Kwan JL, Singh H. Assigning responsibility to close the loop on radiology test results. Diagnosis (Berl). 2017;4(3):173-177. doi:10.1515/dx-2017-0019. https://psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-t…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74753/psn-pdf
    February 09, 2022 - The morbidity and mortality conference: opportunities for enhancing patient safety. February 9, 2022 Lazzara EH, Salisbury M, Hughes AM, et al. The morbidity and mortality conference: opportunities for enhancing patient safety. J Patient Saf. 2022;18(1):e275-e281. doi:10.1097/pts.0000000000000765. https://psnet.ah…
  16. www.ahrq.gov/hai/cauti-tools/phys-championsgd/section9.html
    October 01, 2015 - Resident Physicians as Champions in Preventing Device-Associated Infections Plan To Help Incorporate the Role of Champions for Resident Physicians Previous Page Next Page Table of Contents Resident Physicians as Champions in Preventing Device-Associated Infections Preamble and Summary Epidemiolo…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61089/psn-pdf
    January 01, 2021 - Cognitive bias impact on management of postoperative complications, medical error, and standard of care. November 4, 2020 Antonacci AC, Dechario SP, Antonacci C, et al. Cognitive bias impact on management of postoperative complications, medical error, and standard of care. J Surg Res. 2021;258:47-53. doi:10.1016/j…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43830/psn-pdf
    February 04, 2015 - A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study. February 4, 2015 Morgan L, Pickering S, Hadi M, et al. A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series stu…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47237/psn-pdf
    January 01, 2020 - First-year analysis of the Operating Room Black Box study. July 25, 2018 Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg. 2020;271(1):122-127. doi:10.1097/SLA.0000000000002863. https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study An…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34654/psn-pdf
    June 16, 2011 - Risk mitigation in large scale systems: lessons from high reliability organizations. June 16, 2011 Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-161. https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations The authors examine high-reliability organizations,…