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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40946/psn-pdf
    January 19, 2012 - Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project. January 19, 2012 Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad f…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44958/psn-pdf
    March 09, 2016 - The Sepsis Early Recognition and Response Initiative (SERRI). March 9, 2016 Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt Comm J Qual Patient Saf. 2016;42(3):122-138. https://psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri Early …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38399/psn-pdf
    February 11, 2009 - Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. February 11, 2009 Gurwitz JH, Field T, Rochon P, et al. Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. J…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47875/psn-pdf
    July 19, 2019 - Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review. July 19, 2019 Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a syste…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41557/psn-pdf
    August 01, 2012 - Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. August 1, 2012 Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40904/psn-pdf
    January 04, 2012 - Effect of illness severity and comorbidity on patient safety and adverse events. January 4, 2012 Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456. https://psnet.ahrq.gov/issue/eff…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45310/psn-pdf
    January 03, 2017 - Minding the gaps: assessing communication outcomes of electronic preconsultation exchange. January 3, 2017 Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54. https://psnet.ahrq.gov/issue/mind…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39104/psn-pdf
    February 16, 2011 - Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety? February 16, 2011 Pingleton SK, Horak BJ, Davis DA, et al. Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of qu…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40995/psn-pdf
    January 04, 2012 - Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 4, 2012 van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44-9. doi:10…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50368/psn-pdf
    September 25, 2019 - A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. September 25, 2019 Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. J Am Med Inform As…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46507/psn-pdf
    October 11, 2017 - Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. October 11, 2017 Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs. Health Aff (Millwood). 201…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39947/psn-pdf
    July 03, 2014 - Association between implementation of a medical team training program and surgical mortality. July 3, 2014 Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506. https://psnet.ahrq…
  13. psnet.ahrq.gov/perspective/lesson-vas-team-training-program
    November 01, 2011 - Lesson from the VA's Team Training Program Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD | November 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Neily J, Mills PD, Pa…
  14. psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
    November 01, 2011 - In Conversation With… Eduardo Salas, PhD November 1, 2011  Also Read an Essay Citation Text: In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…
  15. psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
    July 01, 2011 - We are evaluating how to handle our data needs not satisfied by the Common Formats.
  16. psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  17. psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…
  18. psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…
  19. psnet.ahrq.gov/web-mm/not-miscarriage
    June 01, 2005 - Not a Miscarriage Citation Text: Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
    January 01, 2021 - Spotlight Spotlight The Consequences of Miscommunication Regarding a Possible Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kriti Gwal, MD o AHRQ WebM&M Edit…

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