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5341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43335/psn-pdf
      July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is…

5342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46192/psn-pdf
      June 07, 2017 - Investigating the causes of adverse events. June 7, 2017 Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001. https://psnet.ahrq.gov/issue/investigating-causes-adverse-events Incident analysis enab…

5343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42976/psn-pdf
      May 29, 2014 - Quality and safety in pediatric hematology/oncology. May 29, 2014 Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9. doi:10.1002/pbc.24946. https://psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology Children with cancer are particularly vulner…

5344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39374/psn-pdf
      March 17, 2010 - Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. March 17, 2010 Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…

5345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46043/psn-pdf
      April 05, 2017 - High-reliability and the I-PASS communication tool. April 5, 2017 Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse). 2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5. https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool High reliability has y…

5346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60695/psn-pdf
      July 15, 2020 - The coronavirus pandemic’s wider health-care crisis. July 15, 2020 Khullar D. The coronavirus pandemic’s wider health-care crisis. New Yorker. 2020;Jun 29. https://psnet.ahrq.gov/issue/coronavirus-pandemics-wider-health-care-crisis The COVID-19 crisis has disrupted care delivery around the globe. This story discuss…

5347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44144/psn-pdf
      May 27, 2015 - Maintaining safety in the dialysis facility. May 27, 2015 Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95. doi:10.2215/CJN.08960914. https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility Failure to consider human factors and poor communication can contri…

5348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73354/psn-pdf
      June 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. June 2, 2021 National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021. https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop Maternal safety is challenged by clinical, equity…

5349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35375/psn-pdf
      January 02, 2017 - Integrating the intensive care unit safety reporting system with existing incident reporting systems. January 2, 2017 Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Jt Comm J Qual Patient Saf. 2005;31(10):585-93.…

5350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48182/psn-pdf
      August 21, 2019 - Organizational learning in hospitals: a realist review. August 21, 2019 Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091. https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review Organization…

5351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838639/psn-pdf
      October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…

5352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48167/psn-pdf
      August 28, 2019 - ASHP guidelines on perioperative pharmacy services. August 28, 2019 Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073. https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services Pharm…

5353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44488/psn-pdf
      September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare- Associated Infections (HAIs). September 16, 2015 Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15- EHC020-EF. https://p…

5354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39572/psn-pdf
      January 03, 2017 - The tangible handoff: a team approach for advancing structured communication in labor and delivery. January 3, 2017 Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured communication in labor and delivery. Jt Comm J Qual Patient Saf. 2010;36(6):282-287, 241. https:…

5355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846163/psn-pdf
      March 15, 2023 - Using A.I. to detect breast cancer that doctors miss. March 15, 2023 Satariano A, Metz C. New York Times. March 5, 2023. https://psnet.ahrq.gov/issue/using-ai-detect-breast-cancer-doctors-miss Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness im…

5356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866567/psn-pdf
      August 21, 2024 - A daily dose of communication to improve quality and safety outcomes. August 21, 2024 Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care. 2024;33(4):305-310. doi:10.4037/ajcc2024318. https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…

5357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72686/psn-pdf
      January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

5358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47749/psn-pdf
      June 19, 2019 - A simulation-based approach to training in heuristic clinical decision-making. June 19, 2019 Altabbaa G, Raven AD, Laberge J. A simulation-based approach to training in heuristic clinical decision- making. Diagnosis (Berl). 2019;6(2):91-99. doi:10.1515/dx-2018-0084. https://psnet.ahrq.gov/issue/simulation-based-ap…

5359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45526/psn-pdf
      January 01, 2019 - Improving incident reporting among physician trainees. September 28, 2016 Krouss M, Alshaikh J, Croft LD, et al. Improving Incident Reporting Among Physician Trainees. J Patient Saf. 2019;15(4):308-310. doi:10.1097/PTS.0000000000000325. https://psnet.ahrq.gov/issue/improving-incident-reporting-among-physician-train…

5360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842777/psn-pdf
      January 18, 2023 - Patient safety performance: reversing recent declines through shared profession-wide system-level solutions. January 18, 2023 doi:full/10.1056/CAT.22.0318. https://psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared- profession-wide-system The COVID-19 pandemic revealed fractu…