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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41206/psn-pdf
    March 14, 2012 - SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. March 14, 2012 Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50569/psn-pdf
    October 23, 2019 - Design and implementation of a tool for pharmacists to register potential errors in prescribed medication. October 23, 2019 Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register Potential Errors in Prescribed Medication. Stud Health Technol Inform. 2019;264:581-585. d…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844781/psn-pdf
    September 11, 2019 - Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story. September 11, 2019 Botros S, Dunn J. Implementation and spread of a simple and effective way to improve the accuracy of medicine…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44373/psn-pdf
    August 12, 2015 - Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): a systematic review. August 12, 2015 Glymph DC, Olenick M, Barbera S, et al. Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): A Systematic Review. AANA J. 2015;83(3):183-188. https://psnet.ahrq.gov/issue/healthcare-utilizing-del…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47990/psn-pdf
    June 18, 2019 - The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication. June 18, 2019 Hendrickson MA, Schempf EN, Furnival RA, et al. The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication.…

  6. Lost in Transition | PSNet

    psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836885/psn-pdf
    May 16, 2022 - Management of Cardiac Arrest in Unconventional Locations. May 16, 2022 Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations The Case Case #1: An 80-year-old man with history of Parkins…

  8. A Double “Never Event”: Wrong Patient and Wrong Side. | PSNet

    psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side. Citation Text: Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

  9. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet

    psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
    March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? Citation Text: Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…

  10. Interdisciplinary teamwork | PSNet

    psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Interdisciplinary teamwork  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854827/psn-pdf
    October 25, 2023 - Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR. October 25, 2023 Ramjaun A, Hammond Mobilio M, Wright N, et al. Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR. Ann Surg. 2023;278…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47558/psn-pdf
    November 14, 2018 - What we can do about maternal mortality—and how to do it quickly. November 14, 2018 Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.1056/NEJMp1810649. https://psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mo…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34649/psn-pdf
    June 11, 2014 - On error management: lessons from aviation. June 11, 2014 Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. https://psnet.ahrq.gov/issue/error-management-lessons-aviation In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47761/psn-pdf
    May 22, 2019 - Clinicians' perceptions of opioid error–contributing factors in inpatient palliative care services: a qualitative study. May 22, 2019 Heneka N, Bhattarai P, Shaw T, et al. Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study. Palliat Med. 2019;33(4…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73986/psn-pdf
    October 20, 2021 - Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project. October 20, 2021 Lamming L, Montague J, Crosswaite K, et al. Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the H…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45041/psn-pdf
    September 28, 2016 - Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy. September 28, 2016 Bhamidipati S, Elliott DJ, Justice EM, et al. Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850914/psn-pdf
    June 21, 2023 - A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. June 21, 2023 Combs A, Klein VR. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. J Healthc Risk Manag. 2023;43(1):38-42. doi:10.1002/jhrm.21538. https://psnet.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43147/psn-pdf
    July 19, 2017 - ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology. July 19, 2017 Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. doi:10.1097/01.AOG.0000444442.04111.c6. …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60519/psn-pdf
    May 27, 2020 - Reducing the risk of diagnostic error in the COVID-19 era. May 27, 2020 Gandhi TK, Singh H. Reducing the risk of diagnostic error in the COVID-19 era. J. Hosp Med. 2020;15(6):363-366. doi:10.12788/jhm.3461. https://psnet.ahrq.gov/issue/reducing-risk-diagnostic-error-covid-19-era The authors present a nomenclature …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60206/psn-pdf
    April 08, 2020 - Reducing high-risk medication use through pharmacist- led interventions in an outpatient setting. April 8, 2020 Deyo JC, Smith BH, Biola H, et al. Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. J Am Pharm Assoc. 2020. doi:10.1016/j.japh.2020.01.013. https://psnet.a…
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