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1621. Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. | PSNet
      psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp-duodenoscopes-may-impede-effective
      March 11, 2015 - Government Resource Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. Citation Text: Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. FDA Safety Communication. Silver Sp…

1622. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. | PSNet
      psnet.ahrq.gov/issue/reflections-implementing-hospital-wide-provider-based-electronic-inpatient-mortality-review
      August 12, 2020 - Study Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. Citation Text: Mendu ML, Lu Y, Petersen A, et al. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lesson…

1623. How U.S. teams advanced communication and resolution program adoption at local, state and national levels. | PSNet
      psnet.ahrq.gov/issue/how-us-teams-advanced-communication-and-resolution-program-adoption-local-state-and-national
      April 24, 2018 - Study How U.S. teams advanced communication and resolution program adoption at local, state and national levels. Citation Text: LeCraw FR, Stearns SC, McCoy MJ. How U.S. Teams advanced communication and resolution program adoption at local, state and national levels. J Patient Saf Risk M…

1624. Challenges in communication from referring clinicians to pathologists in the electronic health record era. | PSNet
      psnet.ahrq.gov/issue/challenges-communication-referring-clinicians-pathologists-electronic-health-record-era
      June 29, 2011 - Study Challenges in communication from referring clinicians to pathologists in the electronic health record era. Citation Text: Barbieri AL, Fadare O, Fan L, et al. Challenges in Communication from Referring Clinicians to Pathologists in the Electronic Health Record Era. J Pathol Inform.…

1625. Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards. | PSNet
      psnet.ahrq.gov/issue/development-huddle-observation-tool-structured-case-management-discussions-improve-situation
      March 06, 2013 - Study Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards. Citation Text: Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured case management …

1626. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. | PSNet
      psnet.ahrq.gov/issue/communication-gaps-and-readmissions-hospital-patients-aged-75-years-and-older-observational
      July 19, 2023 - Study Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Citation Text: Witherington EMA, Pirzada OM, Avery A. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Hea…

1627. Making surgery as safe as it should be: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/making-surgery-safe-it-should-be-qualitative-study
      July 02, 2014 - Study Making surgery as safe as it should be: a qualitative study. Citation Text: Robinson DJ, Beaumont G. Making surgery as safe as it should be: a qualitative study. Am J Med Qual. 2023;38(5):238-244. doi:10.1097/jmq.0000000000000139. Copy Citation Format: DOI Google Scho…

1628. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. | PSNet
      psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident
      April 16, 2008 - Study Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Citation Text: Arora VM, Johnson JK, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Hea…

1629. Reflection and analysis of how pharmacy students learn to communicate about medication errors. | PSNet
      psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about-medication-errors
      April 12, 2011 - Study Reflection and analysis of how pharmacy students learn to communicate about medication errors. Citation Text: Noland CM, Rickles NM. Reflection and analysis of how pharmacy students learn to communicate about medication errors. Health Commun. 2009;24(4):351-60. doi:10.1080/104102…

1630. Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices. | PSNet
      psnet.ahrq.gov/issue/clinician-perspectives-electronic-health-records-communication-and-patient-safety-across
      September 23, 2020 - Study Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices. Citation Text: Patel MR, Friese CR, Mendelsohn-Victor K, et al. Clinician Perspectives on Electronic Health Records, Communication, and Patient Safety A…

1631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44502/psn-pdf
      May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic Medication Information. May 7, 2018 Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6. https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information How electronic medication-related in…

1632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44142/psn-pdf
      May 03, 2016 - Symposium: Patient Safety: Collaboration, Communication, and Physician Leadership. May 3, 2016 Herndon JH, ed. Clin Orthop Relat Res. 2015;473:1544-1551;1566-1597;1600-1608;1612-1619. https://psnet.ahrq.gov/issue/symposium-patient-safety-collaboration-communication-and-physician- leadership Articles in this speci…

1633. Delayed Recognition of a Positive Blood Culture | PSNet
      psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
      January 29, 2020 - Although systems approaches will help decrease errors in communicating and appropriately treating positive

1634. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45310/psn-pdf
      January 03, 2017 - Minding the gaps: assessing communication outcomes of electronic preconsultation exchange. January 3, 2017 Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54. https://psnet.ahrq.gov/issue/mind…

1635. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74104/psn-pdf
      November 24, 2021 - Examining the meaning of the language used to communicate the nursing hand-off. November 24, 2021 Galatzan BJ, Carrington JM. Examining the meaning of the language used to communicate the nursing hand?off. Res Nurs Health. 2021;44(5):833-843. doi:10.1002/nur.22175. https://psnet.ahrq.gov/issue/examining-meaning-la…

1636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74076/psn-pdf
      November 17, 2021 - Influence of perioperative handoffs on complications and outcomes. November 17, 2021 Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes. Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008. https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…

1637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46043/psn-pdf
      April 05, 2017 - High-reliability and the I-PASS communication tool. April 5, 2017 Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse). 2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5. https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool High reliability has y…

1638. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74019/psn-pdf
      July 11, 2023 - PACT Collaborative: Pathway to Accountability, Compassion and Transparency. July 11, 2023 Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health. https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency Communication and Resolution Programs (CR…

1639. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73970/psn-pdf
      October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences with CRPs. October 13, 2021 Collaborative for Accountability and Improvement. October 21, 2021.  https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…

1640. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45386/psn-pdf
      November 23, 2016 - Balancing doctor egos and errors. November 23, 2016 Sweeney JF. Medical Economics. November 10, 2016. https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors Disclosure and candor with patients after a medical error has gained support from organizations, clinicians, and patients. This magazine article discus…