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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72827/psn-pdf
    March 10, 2021 - Coronavirus Commission for Safety and Quality in Nursing Homes. March 10, 2021 Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020. https://psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes Nursing homes have been confronted with numerous …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46592/psn-pdf
    December 19, 2017 - The evolution of procedural competency in internal medicine training. December 19, 2017 Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014. https://psnet.ahrq.gov/issue/evolution-proce…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39065/psn-pdf
    January 03, 2017 - Family alert: implementing direct family activation of a pediatric rapid response team. January 3, 2017 Ray EM, Smith R, Massie S, et al. Family alert: implementing direct family activation of a pediatric rapid response team. Jt Comm J Qual Patient Saf. 2009;35(11):575-580. https://psnet.ahrq.gov/issue/family-aler…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72667/psn-pdf
    January 20, 2021 - Virtual urgent care quality and safety in the time of Coronavirus. January 20, 2021 Smith SW, Tiu J, Caspers CG, et al. Virtual Urgent Care Quality and Safety in the Time of Coronavirus. Jt Comm J Qual Patient Saf. 2021;47(2):86-98. doi:10.1016/j.jcjq.2020.10.001. https://psnet.ahrq.gov/issue/virtual-urgent-care-q…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48135/psn-pdf
    August 28, 2019 - What causes prescribing errors in children? Scoping review. August 28, 2019 Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680. https://psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-rev…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40207/psn-pdf
    February 09, 2011 - Building nursing intellectual capital for safe use of information technology: a systematic review. February 9, 2011 Poe SS. Building nursing intellectual capital for safe use of information technology: a systematic review. J Nurs Care Qual. 2011;26(1):4-12. doi:10.1097/NCQ.0b013e3181e15c88. https://psnet.ahrq.gov/…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45269/psn-pdf
    November 18, 2016 - Surgeons' disclosures of clinical adverse events. November 18, 2016 Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. 2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787. https://psnet.ahrq.gov/issue/surgeons-disclosures-clinical-adverse-events Even though disclo…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842431/psn-pdf
    January 11, 2023 - Confronting racism in pediatric care. January 11, 2023 Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157. https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care Racism is a patient safety issue that is gaining the increased attention ne…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34737/psn-pdf
    November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems Failure. November 19, 2015 Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000. https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure This video, produced by the Partnership for Patient Safety and the Harvard …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50781/psn-pdf
    January 08, 2020 - Harnessing the power of medical malpractice data to improve patient care. January 8, 2020 Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care. J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393. https://psnet.ahrq.gov/issue/harnessing-power-medic…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34660/psn-pdf
    December 24, 2008 - Building a learning organization. December 24, 2008 Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. https://psnet.ahrq.gov/issue/building-learning-organization Garvin, a Harvard Business School professor, postulates that for organizations to truly improve over time and succeed, they ne…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43529/psn-pdf
    October 01, 2014 - National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014 Kurth D, Tyler D, Heitmiller ES, et al. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014;119(1):112-21. doi:10.1213/ANE.0000000000000040. https://psnet.ahr…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42774/psn-pdf
    May 28, 2015 - Patient safety in plastic surgery: identifying areas for quality improvement efforts. May 28, 2015 Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602. doi:10.1097/SAP.0b013e318297791e. https:…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39450/psn-pdf
    February 17, 2011 - Malpractice reform—opportunities for leadership by health care institutions and liability insurers. February 17, 2011 Mello MM, Gallagher TH. Malpractice reform--opportunities for leadership by health care institutions and liability insurers. N Engl J Med. 2010;362(15):1353-6. doi:10.1056/NEJMp1001603. https://psn…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44617/psn-pdf
    January 22, 2016 - Pediatric prehospital medication dosing errors: a mixed- methods study. January 22, 2016 Hoyle JD, Sleight D, Henry R, et al. Pediatric prehospital medication dosing errors: a mixed-methods study. Prehosp Emerg Care. 2016;20(1):117-124. doi:10.3109/10903127.2015.1061625. https://psnet.ahrq.gov/issue/pediatric-preh…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47978/psn-pdf
    May 01, 2019 - Patient Safety. May 1, 2019 GMS J Med Educ. 2019;36:Doc11-Doc22. https://psnet.ahrq.gov/issue/patient-safety-16 Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education sy…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35234/psn-pdf
    December 11, 2008 - Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes. December 11, 2008 Effken JA, Brewer BB, Patil A, et al. Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes. Int J Med Inform. 2005;74(7-8):605-13. http…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854264/psn-pdf
    October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44649/psn-pdf
    November 11, 2015 - Seven (potentially) deadly prescribing errors. November 11, 2015 Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015. https://psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors Errors in the prescribing process can lead to adverse drug events. This slide set provides information about commo…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851069/psn-pdf
    June 28, 2023 - Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. June 28, 2023 Carthey J. Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. BMJ Qual Saf. 2023;32(8):441-443. doi:10.1136/bmjqs-2022-015680. https://psnet.ahrq.gov/issu…

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