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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38904/psn-pdf
    September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1995-2007. September 2, 2009 Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37135/psn-pdf
    October 04, 2011 - Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. October 4, 2011 Forster AJ, O'Rourke K, Shojania KG, et al. Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event class…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40002/psn-pdf
    January 19, 2011 - Considerations for the design of safe and effective consumer health IT applications in the home. January 19, 2011 Zayas-Cabán T, Dixon BE. Considerations for the design of safe and effective consumer health IT applications in the home. Qual Saf Health Care. 2010;19 Suppl 3:i61-i67. doi:10.1136/qshc.2010.041897. ht…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37098/psn-pdf
    October 04, 2011 - How residents think and make medical decisions: implications for education and patient safety. October 4, 2011 Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for education and patient safety. Am Surg. 2007;73(6):548-553; discussion 553-4. https://psnet.ahrq.gov/…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43512/psn-pdf
    September 29, 2017 - Interruptions and multi-tasking: moving the research agenda in new directions. September 29, 2017 Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372. https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40237/psn-pdf
    February 23, 2011 - The impact of the medical emergency team on the resuscitation practice of critical care nurses. February 23, 2011 Santiano N, Young L, Baramy LS, et al. The impact of the medical emergency team on the resuscitation practice of critical care nurses. BMJ Qual Saf. 2011;20(2):115-20. doi:10.1136/bmjqs.2008.029876. ht…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45619/psn-pdf
    August 16, 2017 - Checking the lists: a systematic review of electronic checklist use in health care. August 16, 2017 Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006. https://psnet.ahrq.gov/issue/checking-lists-s…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34870/psn-pdf
    April 18, 2016 - Unintended medication discrepancies at the time of hospital admission. April 18, 2016 Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-9. https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44057/psn-pdf
    June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE and practice and professional issues items. June 3, 2015 Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and professional issues items. J Nurs Manag. 2014;22(3):421-437. https://psnet.ahrq.gov/issue/measuring-nursing-error-p…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42660/psn-pdf
    October 16, 2013 - Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. October 16, 2013 Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. Acad…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44227/psn-pdf
    November 19, 2018 - A scholarly pathway in quality improvement and patient safety. November 19, 2018 Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med. 2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772. https://psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35749/psn-pdf
    May 09, 2014 - Chemotherapy dose limits set by users of a computer order entry system. May 9, 2014 DuBeshter B; Griggs J; Angel C; Loughner J. https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47135/psn-pdf
    July 25, 2018 - Structured patient handoff on an internal medicine ward: a cluster randomized control trial. July 25, 2018 Tam P, Nijjar AP, Fok M, et al. Structured patient handoff on an internal medicine ward: A cluster randomized control trial. PLoS One. 2018;13(4):e0195216. doi:10.1371/journal.pone.0195216. https://psnet.ahrq…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35176/psn-pdf
    June 23, 2009 - Mapping changes in surgical mortality over 9 years by peer review audit. June 23, 2009 Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39838/psn-pdf
    September 15, 2010 - A multicenter trial of aviation-style training for surgical teams. September 15, 2010 Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea. https://psnet.ahrq.gov/issue/multicenter-trial-aviation-st…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39407/psn-pdf
    March 31, 2010 - What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. March 31, 2010 Parker A, Rubinfeld IS, Azuh O, et al. What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. Am J Surg. 2010;199(3):…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74850/psn-pdf
    February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five stars. February 16, 2022 Rau J. Kaiser Health News. February 8, 2022.  https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars Rating systems face challenges to accurately represent the safety and quality of patient ca…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866823/psn-pdf
    September 25, 2024 - Understanding human factors in patient safety when prescribing. September 25, 2024 Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical Journal. September 2024;313(7989). https://psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing Prescripti…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854634/psn-pdf
    January 01, 2024 - Elopement: evidence-based mitigation and management. October 18, 2023 Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management. Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683. https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management …

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