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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39581/psn-pdf
    January 03, 2017 - An implementation strategy for a multicenter pediatric rapid response system in Ontario. January 3, 2017 Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837763/psn-pdf
    August 03, 2022 - Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019. August 3, 2022 de Kraker MEA, Tartari E, Tomczyk S, et al. Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74267/psn-pdf
    January 19, 2022 - Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Roll Hospitals. January 19, 2022 Marr R, Goyal A, Quinn M, et al. Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Rol…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866554/psn-pdf
    August 21, 2024 - Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams. August 21, 2024 Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams. Jt Comm J Qual Patient Saf. 2024;50(10):737-744. …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764402/psn-pdf
    March 02, 2022 - A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. March 2, 2022 Klein DO, Rennenberg RJMW, Koopmans RP, et al. A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. J Patient Saf. 2021;17(8):e1234-e12…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37776/psn-pdf
    January 31, 2011 - Barcoded medication administration: a last line of defense. January 31, 2011 Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA. 2008;299(18):2200-2. doi:10.1001/jama.299.18.2200. https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense Barcoding techn…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867013/psn-pdf
    October 23, 2024 - Reducing automated dispensing cabinet overrides in the peri-anesthesia care unit: a quality improvement project. October 23, 2024 Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri- anesthesia care unit: a quality improvement project. Jt Comm J Qual Patient Saf. …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60591/psn-pdf
    June 17, 2020 - National trends in the safety performance of electronic health record systems from 2009 to 2018. June 17, 2020 Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547. htt…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38891/psn-pdf
    January 04, 2010 - Do calculation errors by nurses cause medication errors in clinical practice? A literature review. January 4, 2010 Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2009.06.009. https://psnet.ahrq.gov/…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38759/psn-pdf
    April 05, 2010 - Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. April 5, 2010 Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. J Eval Cl…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41777/psn-pdf
    April 05, 2013 - Effect of nonpayment for preventable infections in U.S. hospitals. April 5, 2013 Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367(15):1428-37. doi:10.1056/NEJMsa1202419. https://psnet.ahrq.gov/issue/effect-nonpayment-preventable-infec…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44965/psn-pdf
    February 15, 2017 - Identification and Prioritization of Health IT Patient Safety Measures. February 15, 2017 Washington, DC: National Quality Forum; February 2016. https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures Health information technology (IT) has transformed health care and improv…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839314/psn-pdf
    November 02, 2022 - Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. November 2, 2022 Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Correlation between the number of patient- reported adverse events, adverse drug events, and…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38964/psn-pdf
    November 27, 2009 - Development of a measure of patient safety event learning responses. November 27, 2009 Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x. https://psnet.ahrq.gov/issue/development-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37510/psn-pdf
    March 04, 2011 - Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. March 4, 2011 West AN, Weeks WB, Bagian JP. Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. Health Serv R…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846564/psn-pdf
    March 29, 2023 - While only a few studies reviewed implementation in a clinical setting (most evaluated algorithm technical
  17. psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
    March 15, 2023 - through a certification process where providers can be assessed while taking a BPMH and their skills evaluated
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49714/psn-pdf
    August 21, 2014 - He was re- evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - She paged the on-call team who immediately evaluated the patient and successfully treated him for symptomatic
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49681/psn-pdf
    April 01, 2013 - Providers should document each step in the PN-use process so that any errors can be evaluated and corrective

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