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5641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38831/psn-pdf
      August 05, 2009 - Rural hospital information technology implementation for safety and quality improvement: lessons learned. August 5, 2009 Tietze MF, Williams J, Galimbertti M. Rural hospital information technology implementation for safety and quality improvement: lessons learned. Comput Inform Nurs. 2009;27(4):206-14. doi:10.1097…

5642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40884/psn-pdf
      October 26, 2011 - Get a clue: it can be all too easy to make assessment errors in the field; here's some tips to prevent you from making mistakes. October 26, 2011 Rubin M. Get a clue: It can be all too easy to make assessment errors in the field; here's some tips to prevent you from making mistakes. EMS world. 2011;40(9):57-64. h…

5643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34706/psn-pdf
      December 23, 2012 - Analysing potential harm in Australian general practice: an incident-monitoring study. December 23, 2012 Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident- monitoring study. Med J Aust. 1998;169(2):73-6. https://psnet.ahrq.gov/issue/analysing-potential-harm…

5644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41241/psn-pdf
      June 15, 2012 - Using root cause analysis to reduce falls with injury in the psychiatric unit. June 15, 2012 Lee A, Mills PD, Watts B. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen Hosp Psychiatry. 2012;34(3):304-11. doi:10.1016/j.genhosppsych.2011.12.007. https://psnet.ahrq.gov/issue/using-ro…

5645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42915/psn-pdf
      January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. February 5, 2014 McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively: A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553- 7250(14)40026-6. …

5646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47945/psn-pdf
      August 28, 2019 - Individual and team-based medical error disclosure: dialectical tensions among health care providers. August 28, 2019 Jones M, Scarduzio J, Mathews E, et al. Individual and Team-Based Medical Error Disclosure: Dialectical Tensions Among Health Care Providers. Qual Health Res. 2019;29(8):1096-1108. doi:10.1177/1049…

5647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43294/psn-pdf
      April 25, 2016 - The right and wrong way to talk to patients about adverse events. April 25, 2016 Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics. 2014;91(11):52-5. https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events Apology laws have been explor…

5648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46216/psn-pdf
      July 12, 2017 - Physician satisfaction with transition from CPOE to paper-based prescription. July 12, 2017 Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007. https://psnet.ahrq.gov/issue/phys…

5649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47850/psn-pdf
      March 27, 2019 - Medicines-related harm in the elderly post-hospital discharge. March 27, 2019 Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34. https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge Geriatric patients are particularly vulnerable to medication-related harm. This articl…

5650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43320/psn-pdf
      September 26, 2016 - Identification and interference of intraoperative distractions and interruptions in operating rooms. September 26, 2016 Antoniadis S, Passauer-Baierl S, Baschnegger H, et al. Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res. 2014;188(1):21-29. doi:10.1…

5651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44675/psn-pdf
      July 05, 2016 - Why July matters. July 5, 2016 Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912. doi:10.1097/ACM.0000000000001196. https://psnet.ahrq.gov/issue/why-july-matters Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient mortality increa…

5652. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866809/psn-pdf
      September 25, 2024 - Stop the line: interventions to prevent retained surgical items. September 25, 2024 Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81. doi:10.1002/aorn.14190. https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items Retained surgica…

5653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60230/psn-pdf
      April 15, 2020 - Optimizing patient safety in clinical trials by improving transitions of care. April 15, 2020 Nair SC, Satish KP, Al Maini M, et al. Optimizing patient safety in clinical trials by improving transitions of care. Jt Comm J Qual Patient Saf. 2020;46(4). doi:10.1016/j.jcjq.2020.01.001. https://psnet.ahrq.gov/issue/op…

5654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43931/psn-pdf
      March 04, 2015 - Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. March 4, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015. https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp- duode…

5655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42598/psn-pdf
      September 18, 2013 - Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? September 18, 2013 Weiss CH, Wunderink RG. Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? Curr Opin Crit Care. 2013;19(5):448-52. doi:10.1097/MCC.0b013e328364d53…

5656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47338/psn-pdf
      September 19, 2018 - Avoidable sepsis infections send thousands of seniors to gruesome deaths. September 19, 2018 Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018. https://psnet.ahrq.gov/issue/avoidable-sepsis-infections-send-thousands-seniors-gruesome-deaths Sepsis is a serious condition that can …

5657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46978/psn-pdf
      April 04, 2018 - Using the patient safety huddle as a tool for high reliability. April 4, 2018 Brass SD, Olney G, Glimp R, et al. Using the Patient Safety Huddle as a Tool for High Reliability. Jt Comm J Qual Patient Saf. 2018;44(4):219-226. doi:10.1016/j.jcjq.2017.10.004. https://psnet.ahrq.gov/issue/using-patient-safety-huddle-t…

5658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47235/psn-pdf
      July 11, 2018 - Safety, performance, and satisfaction outcomes in the operating room: a literature review. July 11, 2018 Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review. HERD. 2018;11(2):137-150. doi:10.1177/1937586717705107. https://psnet.ahrq.go…

5659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45001/psn-pdf
      June 01, 2016 - Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units. June 1, 2016 Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and health care-associated infections in critical care units. Intensive Crit Care Nurs…

5660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44821/psn-pdf
      December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. December 5, 2022 Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011. https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture Im…