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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45131/psn-pdf
    July 20, 2016 - Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses. July 20, 2016 Härkänen M, Voutilainen A, Turunen E, et al. Systematic review and meta-analysis of educational interventions designed to improve medication administr…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837961/psn-pdf
    August 31, 2022 - Risk reduction strategy to decrease incidence of retained surgical items. August 31, 2022 Kaplan HJ, Spiera ZC, Feldman DL, et al. Risk reduction strategy to decrease incidence of retained surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/xcs.0000000000000264. https://psnet.ahrq.gov/issue/risk-reduc…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74847/psn-pdf
    February 16, 2022 - Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides. February 16, 2022 Sittig DF, Sengstack P, Singh H. Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides. JAMA. 2022;327(8):719-720. doi:10.1001/ja…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44579/psn-pdf
    September 01, 2016 - Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system. September 1, 2016 Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts i…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41759/psn-pdf
    October 10, 2012 - Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. October 10, 2012 Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the ge…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47799/psn-pdf
    March 20, 2019 - Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. March 20, 2019 Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632. https://psnet.ahrq.gov/issue/deep-medicine-how-artificial-intelligence-can-make-healthcare-human-again This book explores how advancements in technology can impr…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48062/psn-pdf
    August 07, 2019 - Ten ways to improve medication safety in community pharmacies. August 7, 2019 Rupp MT. 10 ways to improve medication safety in community pharmacies. J Am Pharm Assoc (2003). 2019;59(4):474-478. doi:10.1016/j.japh.2019.03.018. https://psnet.ahrq.gov/issue/ten-ways-improve-medication-safety-community-pharmacies Med…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867097/psn-pdf
    November 06, 2024 - Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare. November 6, 2024 Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024. h…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853975/psn-pdf
    September 27, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error. September 27, 2023 Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF. https://psnet.ahrq.gov/issue/strategies-improving-clinician-psychologica…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43065/psn-pdf
    April 09, 2014 - Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care. April 9, 2014 van der Nelson HA, Siassakos D, Bennett J, et al. Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care. A…

  12. 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…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74116/psn-pdf
    November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. November 24, 2021 Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN: 9781945365416. https://psnet.ahrq.gov/issue/ncicle-pathwa…

  14. 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 …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45426/psn-pdf
    August 24, 2016 - Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. August 24, 2016 Lee S-H, Phan PH, Dorman T, et al. Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMC Health Serv Res. 2016;16:254. doi:10.1186/s12913-016-1502…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43715/psn-pdf
    November 26, 2014 - An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. November 26, 2014 Moyer VA, Papile L-A, Eichenwald E, et al. An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. BMJ Qual Saf. 2014;23(12):e3. https://psnet.ahrq.gov/issue/inter…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42697/psn-pdf
    December 05, 2013 - An initiative to improve the management of clinically significant test results in a large health care network. December 5, 2013 Roy CL, Rothschild JM, Dighe AS, et al. An initiative to improve the management of clinically significant test results in a large health care network. Jt Comm J Qual Patient Saf. 2013;39(1…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840489/psn-pdf
    November 30, 2022 - A longitudinal study on the impact of simulation on positive deviance through speaking up. November 30, 2022 M. Violato E. A longitudinal study on the impact of simulation on positive deviance through speaking up. Can J Respir Ther. 2022;58:137-142. doi:10.29390/cjrt-2022-006. https://psnet.ahrq.gov/issue/longitud…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48010/psn-pdf
    May 22, 2019 - In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats. May 22, 2019 Greer JA, Haischer-Rollo G, Delorey D, et al. In-situ Interprofessional Perinatal Drills: The Impact of a Structured Debrief on Maximizing Training While Sensing …

  20. 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…
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