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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38716/psn-pdf
    February 17, 2011 - Ending extra payment for "never events"—stronger incentives for patients' safety. February 17, 2011 Milstein A. Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med. 2009;360(23):2388-90. doi:10.1056/NEJMp0809125. https://psnet.ahrq.gov/issue/ending-extra-payment-never-ev…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50416/psn-pdf
    September 04, 2019 - Perceptual and interpretive error in diagnostic radiology—causes and potential solutions. September 4, 2019 Degnan AJ, Ghobadi EH, Hardy P, et al. Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions. Acad Radiol. 2019;26(6):833-845. doi:10.1016/j.acra.2018.11.006. https://psnet…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38332/psn-pdf
    January 14, 2009 - Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. January 14, 2009 Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8. doi:10.11…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44952/psn-pdf
    March 02, 2016 - Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences. March 2, 2016 Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36559/psn-pdf
    July 14, 2010 - Description and evaluation of an interprofessional patient safety course for health professions and related sciences students. July 14, 2010 Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety Course for Health Professions and Related Sciences Students. J Patie…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45819/psn-pdf
    March 15, 2017 - How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program. March 15, 2017 Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical Judgment-Lessons from an Undiagnosed and Rare Disease Program. Pediatr Clin North A…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60305/psn-pdf
    May 06, 2020 - Medication safety: reducing anesthesia medication errors and adverse drug events in dentistry part I and II. May 6, 2020 Sarasin DS, Brady JW, Stevens RL. Anesth Prog. 2020;67(1):48-59.  https://psnet.ahrq.gov/issue/medication-safety-reducing-anesthesia-medication-errors-and-adverse-drug- events-dentistry Th…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46626/psn-pdf
    December 22, 2018 - What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. December 22, 2018 Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45166/psn-pdf
    May 25, 2016 - Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016 Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151. htt…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837810/psn-pdf
    August 10, 2022 - Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities. August 10, 2022 Atallah F, Hamm RF, Davidson CM, et al. Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunit…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48018/psn-pdf
    July 31, 2019 - PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. July 31, 2019 Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342. doi:10.1097/SIH.0000000000…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37193/psn-pdf
    October 06, 2011 - Incomplete EHR adoption: late uptake of patient safety and cost control functions. October 6, 2011 Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost control functions. Am J Med Qual. 2007;22(5):319-26. https://psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-u…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838930/psn-pdf
    October 26, 2022 - Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. October 26, 2022 Washington DC: United States Government Accountability Office and National Academy of Medicine;  September 2022. Report no. GAO-22-104629. https://psnet.ahrq.gov/issue/ar…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50424/psn-pdf
    September 04, 2019 - From box ticking to the black box: the evolution of operating room safety. September 4, 2019 Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5. https://psnet.ahrq.gov/issue/box-ticking-black-box-e…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42655/psn-pdf
    February 21, 2015 - Perceptions of medical errors in cancer care: an analysis of how the news media describe sentinel events. February 21, 2015 Li JW, Morway L, Velasquez A, et al. Perceptions of medical errors in cancer care: an analysis of how the news media describe sentinel events. J Patient Saf. 2015;11(1):42-51. doi:10.1097/PTS…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44800/psn-pdf
    November 23, 2016 - Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study. November 23, 2016 Collier A, Sorensen R, Iedema R. Patients' and families' perspectives of patient safety at the end of life: a video-reflexive ethnography study. Int J Qual Health Care. 2016;28(1):66-73.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44290/psn-pdf
    April 10, 2023 - Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management. April 10, 2023 Copeland AW. UpToDate. April 10, 2023. https://psnet.ahrq.gov/issue/retained-surgical-sponge-gossypiboma-and-other-retained-surgical-items- prevention-and Retained surgical items are rare and potent…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47574/psn-pdf
    November 21, 2018 - The architecture of safety: an emerging priority for improving patient safety. November 21, 2018 Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643. https://psnet.ahrq.gov/issue/…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45341/psn-pdf
    July 27, 2016 - How to avoid catastrophic events on the ward. July 27, 2016 Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003. https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward Hospitals require robust esca…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839322/psn-pdf
    November 02, 2022 - A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. November 2, 2022 Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839. doi:10.…