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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43129/psn-pdf
    July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. July 23, 2014 Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed- methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331. https://psnet.ahrq.gov/issue/use-d…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43858/psn-pdf
    February 18, 2015 - Hospital system barriers to rapid response team activation: a cognitive work analysis. February 18, 2015 Braaten JS. CE: Original research: hospital system barriers to rapid response team activation: a cognitive work analysis. Am J Nurs. 2015;115(2):22-32; test 33; 47. doi:10.1097/01.NAJ.0000460672.74447.4a. https…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837811/psn-pdf
    August 10, 2022 - Examining the Status of VA’s Electronic Health Record Modernization Program. August 10, 2022 US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022). https://psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program Large-scale electronic health record (EHR) …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837431/psn-pdf
    June 15, 2022 - Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's. June 15, 2022 Clark C. MedPage Today. June 2, 2022 https://psnet.ahrq.gov/issue/anesthesiologist-group-says-hospitals-can-prevent-fatal-errors-vanderbilts Transparency and discussion of errors is a hallmark of the culture needed to i…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46725/psn-pdf
    April 11, 2018 - Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. April 11, 2018 Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?- underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342. doi:10.1016/j.jss.2017.08.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74011/psn-pdf
    October 27, 2021 - Dashboards for visual display of patient safety data: a systematic review. October 27, 2021 Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437. https://psnet.ahrq.gov/issue/dash…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47122/psn-pdf
    June 13, 2018 - Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study. June 13, 2018 Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007. https://psne…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43485/psn-pdf
    December 15, 2014 - Implementation of an emergency department sign-out checklist improves transfer of information at shift change. December 15, 2014 Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg Med. 2014;47(5):580-5. doi:10…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44994/psn-pdf
    October 11, 2017 - Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. October 11, 2017 Franco J, Elghouche AN, Harris MS, et al. Diagnostic Delays and Errors in Head and Neck Cancer Patients: Opportunities for Improvement. Am J Med Qual. 2017;32(3):330-335. doi:10.1177/1062860616638413. ht…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42681/psn-pdf
    December 13, 2013 - Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living. December 13, 2013 Fitzgibbon M, Lorenz R, Lach H. Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living. J Gerontol Nurs. 2013;3…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41087/psn-pdf
    November 26, 2014 - Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes. November 26, 2014 Helms AS, Perez TE, Baltz J, et al. Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes. J Gen Intern Med. 2012;27(3):287-91. doi:10.1007/s…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47009/psn-pdf
    December 21, 2018 - Perceptions of rounding checklists in the intensive care unit: a qualitative study. December 21, 2018 Hallam BD, Kuza CC, Rak K, et al. Perceptions of rounding checklists in the intensive care unit: a qualitative study. BMJ Qual Saf. 2018;27(10):836-843. doi:10.1136/bmjqs-2017-007218. https://psnet.ahrq.gov/issue/…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866411/psn-pdf
    July 31, 2024 - Simulation to Improve Patient Safety: Getting Started. July 31, 2024 Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055. https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73853/psn-pdf
    September 22, 2021 - Incidence of prescription errors in patients discharged from the emergency department. September 22, 2021 Gregory H, Cantley M, Calhoun C, et al. Incidence of prescription errors in patients discharged from the emergency department. Am J Emerg Med. 2021;46:266-270. doi:10.1016/j.ajem.2020.07.061. https://psnet.ahr…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43030/psn-pdf
    March 26, 2014 - Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014 ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.   https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based- causes-vaccine-…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42997/psn-pdf
    May 28, 2014 - Exploring perinatal shift-to-shift handover communication and process: an observational study. May 28, 2014 Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103. https:/…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46369/psn-pdf
    September 06, 2017 - Critical Issues in Food Allergy: A National Academies Consensus Report. September 6, 2017 Sicherer SH, Allen K, Lack G, et al. Critical Issues in Food Allergy: A National Academies Consensus Report. Pediatrics. 2017;140(2). doi:10.1542/peds.2017-0194. https://psnet.ahrq.gov/issue/critical-issues-food-allergy-natio…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48159/psn-pdf
    July 31, 2019 - Fatigue in radiology: a fertile area for future research. July 31, 2019 Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol. 2019;92(1099):20190043. doi:10.1259/bjr.20190043. https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research Physician fatigu…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43791/psn-pdf
    December 17, 2014 - Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. December 17, 2014 Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383. https:…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43184/psn-pdf
    May 14, 2014 - Often overlooked problems with handoffs: from the intensive care unit to the operating room. May 14, 2014 Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075. https://psnet.ahrq.g…