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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34771/psn-pdf
    May 06, 2016 - Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. May 6, 2016 Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414. https://psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition According to Weick and Sutcliffe, high…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866083/psn-pdf
    June 05, 2024 - An invisible disability: communication, patient safety and dual sensory impairment in older persons. June 5, 2024 Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual sensory impairment in older persons. J Adv Nurs. 2024;Epub Mar 22. doi:10.1111/jan.16159. https://p…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865926/psn-pdf
    May 22, 2024 - Critical care nurses' role in rapid response teams: a qualitative systematic review. May 22, 2024 Holtsmark C, Larsen MH, Steindal SA, et al. Critical care nurses' role in rapid response teams: a qualitative systematic review. J Clin Nurs. 2024;33(10):3831-3843. doi:10.1111/jocn.17196. https://psnet.ahrq.gov/issue…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60959/psn-pdf
    September 30, 2020 - Institutional COVID-19 protocols: focused on preparation, safety, and care consolidation. September 30, 2020 DiSilvio B, Virani A, Patel S, et al. Institutional COVID-19 protocols: focused on preparation, safety, and care consolidation. Crit Care Nurs Q. 2020;43(4):413-427. doi:10.1097/cnq.0000000000000327. https:…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43187/psn-pdf
    May 28, 2014 - Governance of quality of care: a qualitative study of health service boards in Victoria, Australia. May 28, 2014 Bismark M, Studdert DM. Governance of quality of care: a qualitative study of health service boards in Victoria, Australia. BMJ Qual Saf. 2014;23(6):474-82. doi:10.1136/bmjqs-2013-002193. https://psnet.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35265/psn-pdf
    February 03, 2011 - A 38-year-old woman with fetal loss and hysterectomy. February 3, 2011 Sachs BP. A 38-Year-Old Woman With Fetal Loss and Hysterectomy. JAMA. 2005;294(7):833-840. doi:10.1001/jama.294.7.833. https://psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy Part of a series in JAMA entitled Clinical Crossro…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44772/psn-pdf
    January 13, 2016 - Post event debriefs: a commitment to learning how to better care for patients and staff. January 13, 2016 Campbell M, Miller K, McNicholas KW. Post Event Debriefs: A Commitment to Learning How to Better Care for Patients and Staff. Jt Comm J Qual Patient Saf. 2016;42(1):41-47. https://psnet.ahrq.gov/issue/post-eve…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41020/psn-pdf
    January 04, 2012 - A 'Communication and Patient Safety' training programme for all healthcare staff: can it make a difference? January 4, 2012 Lee P, Allen K, Daly M. A ‘Communication and Patient Safety’ training programme for all healthcare staff: can it make a difference? BMJ Qual Saf. 2011;21(1). doi:10.1136/bmjqs-2011-000297. ht…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43261/psn-pdf
    June 18, 2014 - Activation of a medical emergency team using an electronic medical recording–based screening system. June 18, 2014 Huh JW, Lim C-M, Koh Y, et al. Activation of a medical emergency team using an electronic medical recording-based screening system*. Crit Care Med. 2014;42(4):801-8. doi:10.1097/CCM.0000000000000031. …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837041/psn-pdf
    May 04, 2022 - APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. May 4, 2022 The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8. https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during- anesthesia Variation across sta…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45009/psn-pdf
    March 30, 2016 - Fatal mistakes. March 30, 2016 Kliff S. Vox Media. March 15, 2016. https://psnet.ahrq.gov/issue/fatal-mistakes Health professionals involved in medical errors experience psychological stress, which can have serious consequences if they are unable to cope with their mistake. Reporting on the second victim phenomeno…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44662/psn-pdf
    January 25, 2016 - The stories clinicians tell: achieving high reliability and improving patient safety. January 25, 2016 Cohen DL, Stewart KO. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety. Perm J. 2016;20(1):85-90. doi:10.7812/TPP/15-039. https://psnet.ahrq.gov/issue/stories-clinicians-tell-a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43109/psn-pdf
    December 10, 2014 - Creating a physician-led quality imperative. December 10, 2014 Nelson MF, Merriman CS, Magnusson PT, et al. Creating a physician-led quality imperative. Am J Med Qual. 2014;29(6):508-16. doi:10.1177/1062860613509683. https://psnet.ahrq.gov/issue/creating-physician-led-quality-imperative This commentary relates one…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45736/psn-pdf
    February 01, 2017 - Disruptive behaviour in the perioperative setting: a contemporary review. February 1, 2017 Villafranca A, Hamlin C, Enns S, et al. Disruptive behaviour in the perioperative setting: a contemporary review. Canadian J Anaesth. 2017;64(2):128-140. doi:10.1007/s12630-016-0784-x. https://psnet.ahrq.gov/issue/disruptive…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44548/psn-pdf
    November 20, 2015 - Safety-II and resilience: the way ahead in patient safety in anaesthesiology. November 20, 2015 Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin Anaesthesiol. 2015;28(6):735-9. doi:10.1097/ACO.0000000000000252. https://psnet.ahrq.gov/issue/safety-ii-and-resilience…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44231/psn-pdf
    January 22, 2016 - Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety. January 22, 2016 Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-9. doi:10.1097/NCQ.0000000000000131.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46741/psn-pdf
    June 07, 2018 - Suffering in silence: medical error and its impact on health care providers. June 7, 2018 Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001. https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46328/psn-pdf
    August 09, 2017 - Critical incident stress debriefing after adverse patient safety events. August 9, 2017 Harrison R, Wu AW. Critical incident stress debriefing after adverse patient safety events. Am J Med Qual. 2017;23(5):310-312. https://psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850912/psn-pdf
    June 21, 2023 - Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? June 21, 2023 Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023. https://psnet.ahrq.gov/issue/racial-ethnic-and-payer-disparities-adverse-safety-events-are…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863227/psn-pdf
    February 28, 2024 - What Do You Do If You Think You Have Been Harmed By Your Healthcare. February 28, 2024 Seattle, WA: Collaborative for Accountability and Improvement; 2023. https://psnet.ahrq.gov/issue/what-do-you-do-if-you-think-you-have-been-harmed-your-healthcare There is a need for patients and families to understand effective…

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