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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37002/psn-pdf
    September 14, 2011 - Factors influencing nurses' decisions to raise concerns about care quality. September 14, 2011 Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag. 2007;15(4):392-402. https://psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38021/psn-pdf
    August 27, 2008 - A review of the current evidence base for significant event analysis. August 27, 2008 Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. https://psnet.ahrq.gov/issue/review-current-evidence-base…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37736/psn-pdf
    April 30, 2008 - Causes of near misses in critical care of neonates and children. April 30, 2008 Tourgeman-Bashkin O, Shinar D, Zmora E. Causes of near misses in critical care of neonates and children. Acta Paediatr. 2008;97(3):299-303. doi:10.1111/j.1651-2227.2007.00616.x. https://psnet.ahrq.gov/issue/causes-near-misses-critical-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40781/psn-pdf
    September 14, 2011 - Reducing the incidence of retained surgical instrument fragments. September 14, 2011 Reece M, Troeleman ND, McGowan JE, et al. Reducing the incidence of retained surgical instrument fragments. AORN J. 2011;94(3):301-4. doi:10.1016/j.aorn.2011.05.014. https://psnet.ahrq.gov/issue/reducing-incidence-retained-surgica…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38338/psn-pdf
    January 14, 2009 - Implementation of patient safety rounds in a children's hospital. January 14, 2009 Yee PL, Edwards ML, Dixon JL, et al. Implementation of patient safety rounds in a children's hospital. Nurs Adm Q. 2009;33(1):48-53. doi:10.1097/01.NAQ.0000343348.93537.41. https://psnet.ahrq.gov/issue/implementation-patient-safety-…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37964/psn-pdf
    June 29, 2011 - Impact of miscommunication in medical dispute cases in Japan. June 29, 2011 Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028. https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-ja…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - appropriate naloxone use.14,15  Individual providers and healthcare systems need to do a better job of identifying
  8. psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
    February 26, 2025 - The NAPSI team designed a protocol that is nimble and flexible to care as it happens instead of only identifying
  9. psnet.ahrq.gov/web-mm/pill-organizing-plight
    June 19, 2018 - SPOTLIGHT CASE A Pill Organizing Plight Citation Text: McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - A Pill Organizing Plight September 1, 2016 McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/pill-organizing-plight Case Objectives Identify patients at high risk for adverse drug events. List drugs that are considered inappropriate in older patients. …
  11. psnet.ahrq.gov/issue/patient-safety-primary-care-has-many-aspects-interview-study-primary-care-doctors-and-nurses
    July 23, 2008 - Study Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. Citation Text: Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pr…
  12. psnet.ahrq.gov/issue/toward-translation-systems-thinking-methods-patient-safety-practice-assessing-validity-net
    April 21, 2021 - Study Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap. Citation Text: Salmon PM, King B, Hulme A, et al. Toward the translation of systems thinking methods in patient safety practice: assessing the validity of…
  13. psnet.ahrq.gov/issue/practice-respect-icu
    August 09, 2018 - Commentary Emerging Classic The practice of respect in the ICU. Citation Text: Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med. 2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP. Copy Citation Format…
  14. psnet.ahrq.gov/issue/safety-medication-use-primary-care
    March 04, 2011 - Review Safety of medication use in primary care. Citation Text: Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract. 2015;23(1):3-20. doi:10.1111/ijpp.12120. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 X…
  15. psnet.ahrq.gov/issue/patient-and-clinician-experiences-uncertainty-diagnostic-process-current-understanding-and
    March 11, 2020 - Commentary Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Citation Text: Meyer AND, Giardina TD, Khawaja L, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding a…
  16. psnet.ahrq.gov/issue/perioperative-patient-safety-recommendations-systematic-review-clinical-practice-guidelines
    January 08, 2025 - Study Perioperative patient safety recommendations: systematic review of clinical practice guidelines. Citation Text: Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. Perioperative patient safety recommendations: systematic review of clinical practice guidelines. BJS Open. 20…
  17. psnet.ahrq.gov/issue/evaluation-measure-dx-resource-accelerate-diagnostic-safety-learning-and-improvement
    February 07, 2024 - Study Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement. Citation Text: Bradford A, Tran A, Ali KJ, et al. Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement. J Gen Intern Med. . 2024;Epub Oct 22. doi:…
  18. psnet.ahrq.gov/issue/situation-background-assessment-recommendation-sbar-communication-tool-handoff-health-care
    March 03, 2021 - Review Emerging Classic Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review. Citation Text: Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for…
  19. psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
    July 24, 2013 - Review Emerging Classic Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature. Citation Text: Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
  20. psnet.ahrq.gov/issue/association-simulation-training-rates-medical-malpractice-claims-among-obstetrician
    December 02, 2020 - Study Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists. Citation Text: Schaffer AC, Babayan A, Einbinder JS, et al. Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists. Ob…

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