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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866111/psn-pdfJune 12, 2024 - Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. June 12, 2024 Gleason KT, Tran A, Fawzy A, et al. Does nurse use of a standardized flowsheet to document commu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39699/psn-pdfNovember 02, 2010 - Medical engagement in organisation-wide safety and quality-improvement programmes: experience in the UK Safer Patients Initiative. November 2, 2010 Parand A, Burnett S, Benn J, et al. Medical engagement in organisation-wide safety and quality- improvement programmes: experience in the UK Safer Patients Initiative.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38639/psn-pdfMay 20, 2009 - Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. May 20, 2009 McCreadie G, Oliver TB. Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38454/psn-pdfJanuary 02, 2017 - Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. January 2, 2017 Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139-45. https://psn… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40304/psn-pdfMarch 23, 2011 - Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds. March 23, 2011 Miller DF, Fortier CR, Garrison KL. Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds. Ann Pharmacoth… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73371/psn-pdfJune 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. June 9, 2021 Leeftink AG, Visser J, de Laat JM, et al. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. Ergonomics. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41858/psn-pdfNovember 21, 2012 - Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. November 21, 2012 Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 2012;177(1):43-8. doi:10.1016/j.jss.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60539/psn-pdfJuly 10, 2017 - Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. July 10, 2017 Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. Jt Comm J Qual Patient Saf. 2017;43(9):433-447. doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72825/psn-pdfMarch 10, 2021 - The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients. March 10, 2021 Urman RD, Seger DL, Fiskio JM, et al. The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients. J Patient Saf. 2021;17(2):e76-e83. doi:10.1097/p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72468/psn-pdfNovember 18, 2020 - Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. November 18, 2020 Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Eff… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/61062/psn-pdfJanuary 01, 2022 - Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. October 28, 2020 Duffy CC, Bass GA, Duncan JR, et al. Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/849329/psn-pdfMay 24, 2023 - Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. May 24, 2023 Hyvämäki P, Sneck S, Meriläinen M, et al. Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36174/psn-pdfSeptember 29, 2010 - Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system. September 29, 2010 Hougland P, Xu W, Pickard S, et al. Performance of International Classification Of Diseases, 9th Revision, Clinical Modification codes as an adverse dr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74698/psn-pdfJanuary 26, 2022 - How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis. January 26, 2022 Etherington C, Kitto S, Burns JK, et al. How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis. BMC Health Serv Res. 2021;21(1):1357. doi:10.1186/s129… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854250/psn-pdfOctober 04, 2023 - Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. October 4, 2023 Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73110/psn-pdfApril 07, 2021 - Does one size fit all? Assessing the need for organizational second victim support programs. April 7, 2021 Edrees HH, Wu AW. Does one size fit all? Assessing the need for organizational second victim support programs. J Patient Saf. 2021;17(3):e247-e254. doi:10.1097/pts.0000000000000321. https://psnet.ahrq.gov/iss… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34763/psn-pdfMarch 07, 2005 - The Limits of Safety: Organizations, Accidents and Nuclear Weapons. March 7, 2005 Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214. https://psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons Two competing paradigms dominate the study of the hazards associate… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42509/psn-pdfAugust 21, 2013 - Explaining Matching Michigan: an ethnographic study of a patient safety program. August 21, 2013 Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70. doi:10.1186/1748-5908-8-70. https://psnet.ahrq.gov/issue/explaining-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/857448/psn-pdfJanuary 01, 2024 - Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. December 6, 2023 Ahmed M, Suhrawardy A, Olszewski A, et al. Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety. J Am Acad Orthop Surg. 2024;… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47313/psn-pdfSeptember 12, 2018 - The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty. September 12, 2018 Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Rooms" Does Not Compromise Out…
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