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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37290/psn-pdf
    February 15, 2011 - Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. February 15, 2011 Singh H, Thomas EJ, Petersen L, et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-6. https://psnet.ahrq.gov/issue/medical-error…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47560/psn-pdf
    January 09, 2019 - Scaling safety: the South Carolina Surgical Safety Checklist experience. January 9, 2019 Berry WR, Edmondson L, Gibbons LR, et al. Scaling Safety: The South Carolina Surgical Safety Checklist Experience. Health Aff (Millwood). 2018;37(11):1779-1786. doi:10.1377/hlthaff.2018.0717. https://psnet.ahrq.gov/issue/scali…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44382/psn-pdf
    June 21, 2016 - Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.' June 21, 2016 Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Qual Saf. …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37843/psn-pdf
    March 04, 2011 - Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. March 4, 2011 Tucker AL, Singer SJ, Hayes J, et al. Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. Health Serv Res. 2008;43(5 Pt 2):1807…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37396/psn-pdf
    March 28, 2012 - Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. March 28, 2012 Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46111/psn-pdf
    May 17, 2017 - Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. May 17, 2017 Mitchell SE, Weigel GM, Laurens V, et al. Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. BMC He…
  7. psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - The error in this case reflects poor clinical judgment and a fund of knowledge deficit. … Errors related to fund of knowledge deficits, inadequate clinical skills, poor clinical judgment, and … The pattern may reflect basic fund of knowledge and clinical skills deficits that are easily remediable
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - Patient Safety in the Ambulatory Care Setting August 5, 2022 Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting Introduction There is no way to review the year 2021 in quality and …
  10. psnet.ahrq.gov/issue/recommendations-no-action-improving-effectiveness-quality-and-safety-recommendations
    January 16, 2025 - Book/Report Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare. Citation Text: Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety In…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46135/psn-pdf
    July 11, 2017 - Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. July 11, 2017 Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215. doi:10.1097/CCM.0000000000…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42819/psn-pdf
    October 31, 2014 - Implementing a national program to reduce catheter- associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. October 31, 2014 Fakih MG, George C, Edson B, et al. Implementing a national prog…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42103/psn-pdf
    January 07, 2015 - Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). January 7, 2015 Galanter W, Falck S, Burns M, et al. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20(3…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38941/psn-pdf
    November 25, 2009 - Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. November 25, 2009 Tjia J, Mazor KM, Field T, et al. Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. J Patient Saf. 2009;5(3):145-152. doi:10.10…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45905/psn-pdf
    December 22, 2017 - Safe practice recommendations for the use of copy- forward with nursing flow sheets in hospital settings. December 22, 2017 Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qual Patient Saf. 2017;43(8):375…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44993/psn-pdf
    April 17, 2017 - Surgical patient safety outcomes in critical access hospitals: how do they compare? April 17, 2017 Natafgi N, Baloh J, Weigel P, et al. Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare? J Rural Health. 2016;33(2):117-126. doi:10.1111/jrh.12176. https://psnet.ahrq.gov/issue/surgica…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42118/psn-pdf
    March 20, 2013 - Simulation exercises as a patient safety strategy: a systematic review. March 20, 2013 Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):426-32. doi:10.7326/0003-4819-158-5-201303051- 00010. https://psnet.ahrq.go…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39970/psn-pdf
    January 22, 2017 - Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. January 22, 2017 Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce central line-associated bloodstream infections. Jt Comm J Qual Patient Saf. 2010;36(11):525-8. htt…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47392/psn-pdf
    January 23, 2019 - Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. January 23, 2019 Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results o…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45319/psn-pdf
    September 01, 2018 - Special Issue: Progress at the Intersection of Patient Safety and Medical Liability. September 1, 2018 Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648. https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability Medical liability refor…

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