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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72586/psn-pdf
    December 23, 2020 - Code Status vs. Care Status December 23, 2020 Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/code-status-vs-care-status Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (AC…
  2. psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
    April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety? Rebecca N. Warburton, PhD | April 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
  3. psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - Establishing a Safety Culture: Thinking Small Timothy J. Hoff, PhD | December 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43643/psn-pdf
    November 04, 2014 - Out-of-hospital medication errors among young children in the United States, 2002–2012. November 4, 2014 Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the United States, 2002-2012. Pediatrics. 2014;134(5):867-76. doi:10.1542/peds.2014-0309. https://psnet.ahrq.g…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43589/psn-pdf
    November 17, 2014 - Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. November 17, 2014 Meeks DW, Meyer AND, Rose B, et al. Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. BMJ Qual Saf. 2014;23…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39438/psn-pdf
    March 23, 2011 - Time to listen: a review of methods to solicit patient reports of adverse events. March 23, 2011 King A, Daniels J, Lim J, et al. Time to listen: a review of methods to solicit patient reports of adverse events. Qual Saf Health Care. 2010;19(2):148-57. doi:10.1136/qshc.2008.030114. https://psnet.ahrq.gov/issue/tim…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42946/psn-pdf
    January 07, 2015 - Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals. January 7, 2015 Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences of implementing commercial compu…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45414/psn-pdf
    August 17, 2016 - The next wave of hospital innovation to make patients safer. August 17, 2016 Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ. https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72512/psn-pdf
    November 25, 2020 - The untold story of a cyberattack, a hospital and a dying woman. November 25, 2020 Ralston W. Wired Magazine. November 11, 2020. https://psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman Health information system downtime can affect patient safety. This story discusses a ransomware incide…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48183/psn-pdf
    August 07, 2019 - Get the Medications Right Institute. August 7, 2019 8230 Old Courthouse Road, Suite 420, Tysons Corner, VA. https://psnet.ahrq.gov/issue/get-medications-right-institute A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports m…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44613/psn-pdf
    October 28, 2015 - Getting rid of "never events" in hospitals. October 28, 2015 Morgenthaler T; Harper CM. https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49642/psn-pdf
    December 01, 2011 - Order Interrupted by Text: Multitasking Mishap December 1, 2011 Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap Case Objectives State the prevalence of mobile devices among clinicians and their common health…
  13. psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
    February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33716/psn-pdf
    September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD September 1, 2011 In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality Improvement and t…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
    March 01, 2015 - PowerPoint Presentation Spotlight Two Wrongs Don't Make a Right (Kidney) This presentation is based on the March 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia Ed…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33563/psn-pdf
    September 16, 2024 - Culture of Safety September 16, 2024 Culture of Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/culture-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837808/psn-pdf
    August 05, 2024 - Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. August 5, 2024 Washington, DC: Leapfrog Group; July 2024. https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals Diagnostic safety is beginning to be established as a systemic, rather than solely an ind…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72655/psn-pdf
    January 20, 2021 - A night in the hospital, from both ends of the stethoscope. January 20, 2021 Ofri D. New York Times. January 5, 2021.  https://psnet.ahrq.gov/issue/night-hospital-both-ends-stethoscope Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. T…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851068/psn-pdf
    June 28, 2023 - Building a Culture of Safety in Health Care. June 28, 2023 Chicago, IL: American Hospital Association: May 2023. https://psnet.ahrq.gov/issue/building-culture-safety-health-care Healthcare-acquired infections (HAIs) are a common complication of hospital care. This report summarizes lessons learned at a series of i…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853627/psn-pdf
    September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023 Health Affairs Forefront; May-September 2023. https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays Diagnostic delays stem from both human and process failures. This series of articles examines how s…

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