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5461. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42915/psn-pdf
      January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. February 5, 2014 McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively: A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553- 7250(14)40026-6. …

5462. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866555/psn-pdf
      August 21, 2024 - Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. August 21, 2024 Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…

5463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45657/psn-pdf
      March 08, 2017 - The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. March 8, 2017 Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30. doi:10.1097/…

5464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849615/psn-pdf
      May 31, 2023 - Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. May 31, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; April 2023. https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications- community-languages Gaps in patient…

5465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47800/psn-pdf
      June 26, 2019 - Error and Uncertainty in Diagnostic Radiology. June 26, 2019 Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395. https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to uncer…

5466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44795/psn-pdf
      June 29, 2016 - Human factors in healthcare: welcome progress, but still scratching the surface. June 29, 2016 Waterson P, Catchpole K. Human factors in healthcare: welcome progress, but still scratching the surface. BMJ Qual Saf. 2016;25(7):480-4. doi:10.1136/bmjqs-2015-005074. https://psnet.ahrq.gov/issue/human-factors-healthca…

5467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46938/psn-pdf
      April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse practitioners. April 25, 2018 Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ. 2018;57(4):203-208. doi:10.3928/01484834-20180322-03. https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…

5468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47737/psn-pdf
      March 06, 2019 - Quality improvement and safety in pediatric emergency medicine. March 6, 2019 Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010. https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…

5469. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44146/psn-pdf
      June 03, 2015 - Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. June 3, 2015 Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049-55. doi:10.1097/AOG.000000000000…

5470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866824/psn-pdf
      September 25, 2024 - 'Failing wisely' can promote a safer healthcare system. September 25, 2024 Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today. September 17, 2024; https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system The ability to learn-by-doing in an enviro…

5471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44853/psn-pdf
      February 03, 2016 - Aviation and healthcare: a comparative review with implications for patient safety. February 3, 2016 Kapur N, Parand A, Soukup T, et al. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open. 2016;7(1):2054270415616548. doi:10.1177/2054270415616548. https://psnet.ahrq.gov/is…

5472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46548/psn-pdf
      April 16, 2018 - Nurses' communication of safety events to nursing home residents and families. April 16, 2018 Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01. https://psnet.ahrq.gov/issue…

5473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45034/psn-pdf
      February 25, 2019 - Future directions for diagnostic decision support. February 25, 2019 Carr S. ImproveDx. April 2016;3:1-3. https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic accuracy. This newsletter article …

5474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60648/psn-pdf
      July 01, 2020 - Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020 Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Foreign Affairs. 2020;99:4. https://psnet.ahrq.gov/issue/chronicle-pan…

5475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42784/psn-pdf
      January 15, 2014 - A multi-disciplinary approach to medication safety and the implication for nursing education and practice. January 15, 2014 Adhikari R, Tocher J, Smith P, et al. A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse Educ Today. 2014;34(2):185-90. doi:10.101…

5476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47274/psn-pdf
      November 21, 2018 - Developing a hospital-wide quality and safety dashboard: a qualitative research study. November 21, 2018 Weggelaar-Jansen AMJWM, Broekharst DSE, de Bruijne M. Developing a hospital-wide quality and safety dashboard: a qualitative research study. BMJ Qual Saf. 2018;27(12):1000-1007. doi:10.1136/bmjqs-2018- 007784. …

5477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46934/psn-pdf
      March 14, 2018 - Engaging the front line: tapping into hospital-wide quality and safety initiatives. March 14, 2018 Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:10.1053/j.jvca.2017.05.038. https://psn…

5478. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48102/psn-pdf
      August 07, 2019 - The unmeasured quality metric: burn out and the second victim syndrome in healthcare. August 7, 2019 Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011. https://psnet.ahrq.gov/issue/u…

5479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47064/psn-pdf
      August 22, 2018 - Lax oversight leaves surgery center regulators and patients in the dark. August 22, 2018 Jewett C, Alesia M. Kaiser Health News. August 9, 2018. https://psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark High-profile failures during office-based procedures have raised awareness o…

5480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45716/psn-pdf
      September 29, 2017 - Microanalysis of video from the operating room: an underused approach to patient safety research. September 29, 2017 Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…