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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74269/psn-pdf
    January 19, 2022 - Safety culture, safety climate, and safety performance in healthcare facilities: a systematic review. January 19, 2022 Noor Arzahan IS, Ismail Z, Yasin SM. Safety culture, safety climate, and safety performance in healthcare facilities: A systematic review. Safety Sci. 2022;147:105624. doi:10.1016/j.ssci.2021.10562…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839812/psn-pdf
    November 09, 2022 - Measuring psychological safety and local learning to enable high reliability organisational change. November 9, 2022 Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high reliability organisational change. BMJ Open Qual. 2022;11(4):e001757. doi:10.1136/bmjoq-2021-00175…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46141/psn-pdf
    May 17, 2017 - Ethical dilemma in missed melanoma: what to tell the patient and other providers. May 17, 2017 Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016.08.030. https://psnet.ahrq.gov/issue/et…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47438/psn-pdf
    June 02, 2019 - Developing an intervention to reduce harm in hospitalized patients: patients and families in research. June 2, 2019 Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278. doi:10.1097/NCQ.0…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36680/psn-pdf
    July 10, 2008 - Identifying diagnostic errors in primary care using an electronic screening algorithm. July 10, 2008 Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007;167(3):302-308. https://psnet.ahrq.gov/issue/identifying-diagnostic-e…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34700/psn-pdf
    January 04, 2017 - Reducing adverse drug events: lessons from a breakthrough series collaborative. January 4, 2017 Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31. https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49546/psn-pdf
    October 17, 2007 - Do Not Disturb! October 1, 2007 Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/do-not-disturb Case Objectives Define professionalism. Discuss behaviors associated with lack of professionalism. Outline steps one should take if a significant breach of professionalism is …
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49506/psn-pdf
    March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/wet-read Case Objectives Appreciate the limitations of radiology resident emergency coverage. Understand the rate of discrepancy between radiology resident preliminary reads and attending radiologists' fina…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49786/psn-pdf
    March 01, 2017 - Consequences of Medical Overuse March 1, 2017 Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/consequences-medical-overuse Case Objectives Define overuse and overdiagnosis. State how much of all care is estimated to be overuse. Describe why the likelihood…
  13. psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. Citation Text: Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72835/psn-pdf
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60701/psn-pdf
    July 22, 2020 - Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. July 22, 2020 Alqenae FA, Steinke DT, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38347/psn-pdf
    May 24, 2015 - Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. May 24, 2015 Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF. https://psnet.ahrq.gov/issue/usin…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46113/psn-pdf
    July 12, 2017 - Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance. July 12, 2017 Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-in…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850172/psn-pdf
    June 07, 2023 - Clinical nurse competence and its effect on patient safety culture: a systematic review. June 7, 2023 Zaitoun RA, Said NB, de Tantillo L. Clinical nurse competence and its effect on patient safety culture: a systematic review. BMC Nurs. 2023;22(1):173. doi:10.1186/s12912-023-01305-w. https://psnet.ahrq.gov/issue/c…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865967/psn-pdf
    May 29, 2024 - Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. May 29, 2024 Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. Diagnosis…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844777/psn-pdf
    September 18, 2019 - Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. September 18, 2019 Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents. J Patient Saf. 2019;15(3):191-197. doi:10…

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