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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838193/psn-pdf
    September 28, 2022 - Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. September 28, 2022 de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147. …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45561/psn-pdf
    January 01, 2021 - Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). November 2, 2016 Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3):e234-e240. https://psnet.ahrq.g…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47278/psn-pdf
    August 15, 2018 - Drawing boundaries: the difficulty in defining clinical reasoning. August 15, 2018 Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142. https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47279/psn-pdf
    July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the Home. July 23, 2018 Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence ass…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44384/psn-pdf
    August 12, 2015 - Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. August 12, 2015 Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag. 2015;35(1):21-30. doi:10.1002/jhrm.21174…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43850/psn-pdf
    March 11, 2015 - Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice. March 11, 2015 Gupta RT, Sexton B, Milne J, et al. Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice…
  7. 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.…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46474/psn-pdf
    November 08, 2017 - Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. November 8, 2017 St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017. https://psnet.ahrq.gov/issue/cle…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46982/psn-pdf
    June 13, 2018 - Advances in perioperative quality and safety. June 13, 2018 Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Advances in perioperative quality and safety. Semin Pediatr Surg. 2018;27(2):92-101. doi:10.1053/j.sempedsurg.2018.02.006. https://psnet.ahrq.gov/issue/advances-perioperative-quality-and-safety Clinical s…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35909/psn-pdf
    October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing Harm to Patients. October 7, 2008 McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006. https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients This report presents ten case studies to illustrate interventions that address p…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44130/psn-pdf
    May 13, 2015 - Recent Evidence That Health IT Improves Patient Safety: Issue Brief. May 13, 2015 Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information Technology; February 2015. https://psnet.ahrq.gov/issue/recent-evidence-health-it-improves-patient-safety-issue-brief Rapid implementatio…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45822/psn-pdf
    April 24, 2018 - Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. April 24, 2018 Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. J Am Med Inform Assoc. 2017…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43257/psn-pdf
    August 14, 2014 - Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. August 14, 2014 Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60190/psn-pdf
    April 01, 2020 - Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary. April 1, 2020 Maxwell J, Bourgoin A, Crandall J. Potentially Preventable Readmissions: Conceptual Framework To Rethink The Role Of Primary Care. Executive Summary. Rockville, MD : Agency for Healthcar…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46447/psn-pdf
    September 27, 2017 - Creating highly reliable accountable care organizations. September 27, 2017 Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev. 2016;73(6):660-672. https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations High reliability is a goal throughout …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46172/psn-pdf
    June 21, 2017 - Flying lessons for clinicians: developing system 2 practice. June 21, 2017 Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003. https://psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-p…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43637/psn-pdf
    April 25, 2016 - Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care. April 25, 2016 Gray D, Johnson KD, Watts B. Lost In Translation? Addressing Barriers in the Application of Industrial Process Improvement Methodologies to Health Care. Jt Comm J Qual Patient …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45339/psn-pdf
    August 10, 2016 - Hospital at night: an organizational design that provides safer care at night. August 10, 2016 Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17. https://psnet.ahrq.gov/issue/hospi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45961/psn-pdf
    June 23, 2017 - Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database. June 23, 2017 Poudel DR, Acharya P, Ghimire S, et al. Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database. Pharmacoe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844802/psn-pdf
    September 18, 2019 - Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery. September 18, 2019 DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to Improve Patient Safety and Quality Associ…