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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40955/psn-pdf
    March 08, 2017 - Kaiser Permanente's performance improvement system, part 4: creating a learning organization. March 8, 2017 Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011;37(12):532-43. https://psnet.ahrq.gov/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37596/psn-pdf
    May 01, 2016 - Patient Safety Organization (PSO) Program. May 1, 2016 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient care," the Agency for Healthcare Research…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836868/psn-pdf
    April 06, 2022 - HEAR Her Concerns. April 6, 2022 National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.  https://psnet.ahrq.gov/issue/hear-her-concerns Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45856/psn-pdf
    April 12, 2018 - NAM Action Collaborative on Clinician Well-Being and Resilience. April 12, 2018 Washington, DC: National Academy of Medicine. https://psnet.ahrq.gov/issue/nam-action-collaborative-clinician-well-being-and-resilience Clinician burnout can affect the ability of individuals to act safely. This website highlights the …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37176/psn-pdf
    January 02, 2017 - Using an automated risk assessment report to identify patients at risk for clinical deterioration. January 2, 2017 Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient Saf. 2007;33(9):569-74. https://psnet.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45590/psn-pdf
    August 02, 2017 - Improving Diagnostic Accuracy Project 2016–2017. August 2, 2017 Washington, DC: National Quality Forum; October 2016. https://psnet.ahrq.gov/issue/improving-diagnostic-accuracy-project-2016-2017 The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This we…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45169/psn-pdf
    June 08, 2016 - High Reliability in Health Care. June 8, 2016 Joint Commission Center for Transforming Healthcare. https://psnet.ahrq.gov/issue/high-reliability-health-care Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867532/psn-pdf
    January 15, 2025 - Maternal Health Indicators. January 15, 2025 Maternal Health Indicators. Agency for Healthcare Quality and Research. 2024. https://psnet.ahrq.gov/issue/maternal-health-indicators Maternal health care faces a variety of patient safety challenges. This set of quality indicators supports the epidemiological or resear…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45931/psn-pdf
    July 05, 2017 - The CARE approach to reducing diagnostic errors. July 5, 2017 Rush JL, Helms SE, Mostow EN. The CARE approach to reducing diagnostic errors. Int J Dermatol. 2017;56(6):669-673. doi:10.1111/ijd.13532. https://psnet.ahrq.gov/issue/care-approach-reducing-diagnostic-errors Cognitive aids such as checklists and mnemoni…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862616/psn-pdf
    February 14, 2024 - Engaging Patients for Patient Safety: Advocacy Brief. February 14, 2024 WHO Patient Safety Flagship. Geneva; World Health Organization; December 2023. ISBN: 9789240081987. https://psnet.ahrq.gov/issue/engaging-patients-patient-safety-advocacy-brief Patients and families are important, yet underutilized, partn…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44091/psn-pdf
    January 04, 2019 - Isolation precautions for visitors. January 4, 2019 Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67. https://psnet.ahrq.gov/issue/isolation-precautions-visitors This expert guidance provides recommendations …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40742/psn-pdf
    May 28, 2014 - Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. May 28, 2014 Lutgendorf MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Mil Med. 2011;176(6):702-704. https://psnet.ahrq.gov/issue/implementa…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39050/psn-pdf
    January 04, 2010 - Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study. January 4, 2010 de Neef M, Bos AP, Tol D. Safety as a criterion for quality: the critical nursing situation index in paediatric critical care, an observational study. Intensive Crit Care Nur…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43607/psn-pdf
    October 15, 2014 - Dallas Ebola case shows even sound plans can fail spectacularly. October 15, 2014 Loftis RL. Dallas Morning News. October 5, 2014. https://psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly Guidelines and rules are developed to help augment safety, but they cannot guarantee it. Th…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40447/psn-pdf
    March 04, 2015 - Analysis and prioritization of near-miss adverse events in a radiology department. March 4, 2015 Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373. https://psnet.ahrq.gov/issu…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36547/psn-pdf
    January 10, 2011 - The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. January 10, 2011 Kerfoot KM, Rapala K, Ebright PR, et al. The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. J Nurs Adm. 200…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42974/psn-pdf
    September 07, 2016 - Chemotherapy drug shortages in pediatric oncology: a consensus statement. September 7, 2016 Decamp M, Joffe S, Fernandez C, et al. Chemotherapy drug shortages in pediatric oncology: a consensus statement. Pediatrics. 2014;133(3):e716-24. doi:10.1542/peds.2013-2946. https://psnet.ahrq.gov/issue/chemotherapy-drug-sh…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36337/psn-pdf
    October 26, 2010 - Technology, governance and patient safety: systems issues in technology and patient safety. October 26, 2010 Balka E, Doyle-Waters M, Lecznarowicz D, et al. Technology, governance and patient safety: systems issues in technology and patient safety. Int J Med Inform. 2007;76 Suppl 1:S35-47. https://psnet.ahrq.gov/i…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39440/psn-pdf
    September 19, 2016 - Toward understanding errors in inpatient psychiatry: a qualitative inquiry. September 19, 2016 Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z. https://psnet.ahrq.gov/issue/toward-understanding…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44567/psn-pdf
    October 14, 2015 - The misery of a doctor's first days. October 14, 2015 Hester JL. The Atlantic. October 1, 2015. https://psnet.ahrq.gov/issue/misery-doctors-first-days Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine the difficulties associated with the first days of pra…

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