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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50457/psn-pdf
    October 09, 2019 - Combined SNA and LDA methods to understand adverse medical events October 9, 2019 Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. https://psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understa…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44363/psn-pdf
    May 05, 2018 - Selection of incorrect medication pump leads to chemotherapy overdose. May 5, 2018 ISMP Canada. August 26, 2015;15:1-4. https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45176/psn-pdf
    July 20, 2016 - Sustaining Improvement. July 20, 2016 Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. https://psnet.ahrq.gov/issue/sustaining-improvement Numerous activities and programs have been launched to improve patient safety, but sustaining improvements can be …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45777/psn-pdf
    January 11, 2017 - Disclosure of adverse events in pediatrics. January 11, 2017 McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management; Council on Quality Improvement and Patient Safety. Pediatrics. 2016;138(6);e20163215. https://psnet.ahrq.gov/issue/disclosure-adverse-events-pediatrics Op…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45450/psn-pdf
    February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons. February 13, 2018 London, UK: Royal College of Surgeons of England; 2016. https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for sur…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35304/psn-pdf
    July 14, 2009 - Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events. July 14, 2009 DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events. Med Care. 2005;43(9 Suppl):III63-II…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41598/psn-pdf
    August 15, 2012 - Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifestyle for physicians? August 15, 2012 Olson R, Garite TJ, Fishman A, et al. Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifesty…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838139/psn-pdf
    September 21, 2022 - Error traps in acute pain management in children. September 21, 2022 Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr Anaesth. 2022;32(9):982-992. doi:10.1111/pan.14514. https://psnet.ahrq.gov/issue/error-traps-acute-pain-management-children Appropriate pediatric pain…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866359/psn-pdf
    June 01, 2022 - Diagnostic Safety Toolkit. June 1, 2022 Diagnostic Safety Toolkit. https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0 Effective communication is critical as patients shift from one level of care to another as their diagnosis evolves. This toolkit is designed to help academic medical centers initiate conversa…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44135/psn-pdf
    November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the NHS. November 6, 2015 Francis R. London, UK: Department of Health; February 2015. https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs Staff willingness to raise awareness of problems that could affect patient care is an important indicator of …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44565/psn-pdf
    October 14, 2015 - How to use online clinician rating systems. October 14, 2015 Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA. 2015;314(13):1418. doi:10.1001/jama.2015.11957. https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems Clinician rating sites may not always pr…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44966/psn-pdf
    March 16, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. March 16, 2016 McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF. https://psnet.ahrq.gov/issue/confidential-physician-feedback-rep…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41356/psn-pdf
    May 29, 2012 - Safety in the home healthcare sector: development of a new household safety checklist. May 29, 2012 Gershon RRM, Dailey M, Magda LA, et al. Safety in the home healthcare sector: development of a new household safety checklist. J Patient Saf. 2012;8(2):51-9. doi:10.1097/PTS.0b013e31824a4ad6. https://psnet.ahrq.gov/…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44567/psn-pdf
    October 14, 2015 - The misery of a doctor's first days. October 14, 2015 Hester JL. The Atlantic. October 1, 2015. https://psnet.ahrq.gov/issue/misery-doctors-first-days Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine the difficulties associated with the first days of pra…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44016/psn-pdf
    November 21, 2016 - Partnering to Improve Quality and Safety: A Framework for Working With Patient and Family Advisors. November 21, 2016 Chicago, IL: Health Research & Educational Trust; 2015. https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family- advisors Patient and family advisor…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44091/psn-pdf
    January 04, 2019 - Isolation precautions for visitors. January 4, 2019 Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67. https://psnet.ahrq.gov/issue/isolation-precautions-visitors This expert guidance provides recommendations …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45606/psn-pdf
    October 27, 2016 - Unprofessional workplace conduct...defining and defusing it. October 27, 2016 MacLean L, Coombs C, Breda K. Unprofessional workplace conduct..defining and defusing it. Nurs Manage. 2016;47(9):30-34. doi:10.1097/01.NUMA.0000491126.68354.be. https://psnet.ahrq.gov/issue/unprofessional-workplace-conductdefining-and-d…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43936/psn-pdf
    December 04, 2015 - Exploring the Potential Use of Safety Cases in Health Care. December 4, 2015 Safety Cases Working Group. London, UK: Health Foundation; 2015. https://psnet.ahrq.gov/issue/exploring-potential-use-safety-cases-health-care This report describes a consensus-building initiative in the United Kingdom seeking to determin…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41222/psn-pdf
    May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO). May 1, 2016 Agency for Healthcare Quality and Research. https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization- pso Patient safety organizations (PSO) present a unique o…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43948/psn-pdf
    May 20, 2015 - Human factors engineering: its place and potential in OR safety. May 20, 2015 Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3. doi:10.1016/j.aorn.2015.02.013. https://psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety Human fa…