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2941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45620/psn-pdf
      December 07, 2016 - A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. December 7, 2016 Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(4):173-179. https://psnet.ahrq.g…

2942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46398/psn-pdf
      June 25, 2018 - Challenges in health care simulation: are we learning anything new? June 25, 2018 Henriksen K, Rodrick D, Grace EN, et al. Challenges in Health Care Simulation: Are We Learning Anything New? Acad Med. 2018;93(5):705-708. doi:10.1097/ACM.0000000000001891. https://psnet.ahrq.gov/issue/challenges-health-care-simulati…

2943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50561/psn-pdf
      October 16, 2019 - Patient Safety Organizations: Hospital Participation, Value, and Challenges. October 16, 2019 US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG Report No. OEI-01-17-00420.  https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and…

2944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44449/psn-pdf
      January 22, 2016 - Do patient safety indicators explain increased weekend mortality? January 22, 2016 Ricciardi R, Nelson J, Francone TD, et al. Do patient safety indicators explain increased weekend mortality? J Surg Res. 2016;200(1):164-70. doi:10.1016/j.jss.2015.07.030. https://psnet.ahrq.gov/issue/do-patient-safety-indicators-ex…

2945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44625/psn-pdf
      November 20, 2015 - State-of-the-art usage of simulation in anesthesia: skills and teamwork. November 20, 2015 Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257. https://psnet.ahrq.gov/issue/state-art-usage-simulati…

2946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44024/psn-pdf
      October 13, 2015 - Cultivating a culture of medication safety in prelicensure nursing students. October 13, 2015 Bush PA, Hueckel RM, Robinson D, et al. Cultivating a Culture of Medication Safety in Prelicensure Nursing Students. Nurse Educ. 2015;40(4):169-73. doi:10.1097/NNE.0000000000000148. https://psnet.ahrq.gov/issue/cultivatin…

2947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44032/psn-pdf
      April 01, 2015 - ACOG Committee Opinion #621: patient safety and health information technology. April 1, 2015 Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a. https://psnet.ahrq.gov/i…

2948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43596/psn-pdf
      December 19, 2014 - The role of the anesthesiologist in perioperative patient safety. December 19, 2014 Wacker J, Staender S. The role of the anesthesiologist in perioperative patient safety. Curr Opin Anaesthesiol. 2014;27(6):649-656. doi:10.1097/ACO.0000000000000124. https://psnet.ahrq.gov/issue/role-anesthesiologist-perioperative-…

2949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47165/psn-pdf
      June 13, 2018 - Changing how we think about healthcare improvement. June 13, 2018 Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014. doi:10.1136/bmj.k2014. https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement In learning organizations, leadership behavior creates a s…

2950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44046/psn-pdf
      August 21, 2015 - Development of an instrument to measure the unintended consequences of EHRs. August 21, 2015 Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083. https://psnet.ahrq.gov/issue/devel…

2951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45506/psn-pdf
      November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

2952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47577/psn-pdf
      January 16, 2019 - Reversing the rise in maternal mortality. January 16, 2019 Kozhimannil KB. Reversing The Rise In Maternal Mortality. Health Aff (Millwood). 2018;37(11):1901-1904. doi:10.1377/hlthaff.2018.1013. https://psnet.ahrq.gov/issue/reversing-rise-maternal-mortality Maternal harm is a sentinel event that is gaining increase…

2953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45263/psn-pdf
      September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…

2954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72582/psn-pdf
      December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. December 16, 2020 Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11. https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died I…

2955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43365/psn-pdf
      November 19, 2016 - Identifying facilitators and barriers for patient safety in a medicine label design system using patient simulation and interviews. November 19, 2016 Dieckmann P, Clemmensen MH, Sørensen TK, et al. Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design System Using Patient Simulation a…

2956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47038/psn-pdf
      July 18, 2018 - Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. July 18, 2018 Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906. https://psnet.ahrq.gov/issue/delivering-quality-health-services-global-imperative-universal-health-coverage The Crossing the Quality C…

2957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39197/psn-pdf
      January 06, 2010 - root-cause-analysis https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety

2958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43027/psn-pdf
      July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar

2959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44513/psn-pdf
      September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing

2960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47516/psn-pdf
      December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management, which