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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35059/psn-pdf
    June 22, 2009 - Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit.   June 22, 2009 Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit. Pharmacotherapy. 2005;25…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42487/psn-pdf
    September 27, 2017 - 'Safe enough in here?': Patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. September 27, 2017 Stenhouse RC. 'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. J Clin Nurs. 2013;22(21-22):3109-19. doi:10.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45320/psn-pdf
    January 01, 2017 - The problem with the '5 whys.' September 14, 2016 Card AJ. The problem with '5 whys'. BMJ Qual Saf. 2017;26(8):671-677. doi:10.1136/bmjqs-2016-005849. https://psnet.ahrq.gov/issue/problem-5-whys Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and incomplete res…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38926/psn-pdf
    November 13, 2009 - "Canary measures" among the AHRQ Patient Safety Indicators. November 13, 2009 Yu H, Greenberg MD, Haviland AM, et al. "Canary measures" among the AHRQ patient safety indicators. Am J Med Qual. 2009;24(6):465-73. doi:10.1177/1062860609341585. https://psnet.ahrq.gov/issue/canary-measures-among-ahrq-patient-safety-in…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38702/psn-pdf
    June 10, 2009 - An exploratory study measuring verbal order content and context. June 10, 2009 Wakefield DS, Brokel J, Ward MM, et al. An exploratory study measuring verbal order content and context. Qual Saf Health Care. 2009;18(3):169-73. doi:10.1136/qshc.2008.029827. https://psnet.ahrq.gov/issue/exploratory-study-measuring-ver…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40447/psn-pdf
    March 04, 2015 - Analysis and prioritization of near-miss adverse events in a radiology department. March 4, 2015 Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373. https://psnet.ahrq.gov/issu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60741/psn-pdf
    July 29, 2020 - As college students return, a crisis in campus care awaits. July 29, 2020 Abelson J, Tran AB, Kornfield M, et al. As college students return, a crisis in campus care awaits. The Seattle Times. 2020;July 13. https://psnet.ahrq.gov/issue/college-students-return-crisis-campus-care-awaits The COVID-19 pandemic has im…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47791/psn-pdf
    March 20, 2019 - Essential activities for electronic health record safety: a qualitative study. March 20, 2019 Ash JS, Singh H, Wright A, et al. Essential activities for electronic health record safety: A qualitative study. Health Informatics J. 2019:1460458219833109. doi:10.1177/1460458219833109. https://psnet.ahrq.gov/issue/esse…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72685/psn-pdf
    January 27, 2021 - Human Factors and Ergonomics in Healthcare. January 27, 2021 Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.    https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare Human factors approaches have been identified as one of the primary vehicles to create las…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73327/psn-pdf
    January 25, 2022 - ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur. This asses…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39440/psn-pdf
    September 19, 2016 - Toward understanding errors in inpatient psychiatry: a qualitative inquiry. September 19, 2016 Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z. https://psnet.ahrq.gov/issue/toward-understanding…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36166/psn-pdf
    June 14, 2011 - Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals. June 14, 2011 Worster A, Fernandes CMB, Malcolmson C, et al. Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals. J Emerg Nurs. 2006;32(4):276-280. https://psnet.ahrq.gov…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42631/psn-pdf
    November 08, 2013 - "That was a close call": endorsing a broad definition of near misses in health care. November 8, 2013 Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479. https://psnet.ahrq.gov/issue/was-close-call…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36905/psn-pdf
    September 01, 2011 - Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. September 1, 2011 Brand C, Ibrahim JE, Bain C, et al. Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. Intern Med J. 2007;37(5):295-302. https://psnet.ahrq.gov/issu…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36841/psn-pdf
    December 31, 2014 - Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. December 31, 2014 Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30. https://psnet.ahrq.gov/issue/using-medica…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42780/psn-pdf
    June 17, 2014 - Intrathecal chemotherapy: potential for medication error. June 17, 2014 Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108. https://psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error This systematic review of …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42452/psn-pdf
    July 31, 2013 - Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. July 31, 2013 Ahmed K, Khan N, Khan MS, et al. Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. BJU Int. 2013;111(7):1161-74. do…
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865588/psn-pdf
    April 17, 2024 - Inattentional blindness in medicine. April 17, 2024 Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18. doi:10.1186/s41235-024-00537-x. https://psnet.ahrq.gov/issue/inattentional-blindness-medicine Inattentional blindness occurs when a person is focused so int…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38812/psn-pdf
    April 12, 2011 - Management of test results in family medicine offices. April 12, 2011 Elder NC, McEwen TR, Flach JM, et al. Management of test results in family medicine offices. Ann Fam Med. 2009;7(4):343-51. doi:10.1370/afm.961. https://psnet.ahrq.gov/issue/management-test-results-family-medicine-offices This study evaluated co…

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