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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43553/psn-pdf
    August 28, 2017 - Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. August 28, 2017 Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Saf. 2014;13(3):111-121. doi:10.1…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44709/psn-pdf
    November 18, 2016 - Lost information during the handover of critically injured trauma patients: a mixed-methods study. November 18, 2016 Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48130/psn-pdf
    August 07, 2019 - Adverse events in long-term care residents transitioning from hospital back to nursing home. August 7, 2019 Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:10.1001/jamainternmed.2019.2005. …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40024/psn-pdf
    December 21, 2014 - Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children. December 21, 2014 Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1 946 831 operations in child…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45407/psn-pdf
    September 27, 2016 - Safety of the Manchester Triage System to detect critically ill children at the emergency department. September 27, 2016 Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department. J Pediatr. 2016;177:232-237.e1. doi:10.1016/j.j…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41408/psn-pdf
    October 19, 2012 - Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011. October 19, 2012 Guh AY, Thompson ND, Schaefer MK, et al. Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001-201…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44522/psn-pdf
    June 21, 2016 - Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis. June 21, 2016 Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop com…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43788/psn-pdf
    February 25, 2015 - Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys. February 25, 2015 Singer SJ, Nieva HR, Brede N, et al. Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys. Med Care. 2015;53(2):141-52. doi:10.1097/MLR.000000000…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43170/psn-pdf
    December 12, 2014 - Effects of patient-, environment- and medication-related factors on high-alert medication incidents. December 12, 2014 Manias E, Williams A, Liew D, et al. Effects of patient-, environment- and medication-related factors on high-alert medication incidents. Int J Qual Health Care. 2014;26(3):308-20. doi:10.1093/intq…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46975/psn-pdf
    November 16, 2018 - Electronic health record usability issues and potential contribution to patient harm. November 16, 2018 Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278. doi:10.1001/jama.2018.1171. https://psnet.ahrq.gov/issue…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46806/psn-pdf
    January 01, 2020 - Examining the relationship of an all-cause harm patient safety measure and critical performance measures at the frontline of care. February 28, 2018 Sammer C, Hauck L, Jones C, et al. Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measures at the Frontline of Care. …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46232/psn-pdf
    February 10, 2018 - Implications of electronic health record downtime: an analysis of patient safety event reports. February 10, 2018 Larsen E, Fong A, Wernz C, et al. Implications of electronic health record downtime: an analysis of patient safety event reports. J Am Med Inform Assoc. 2018;25(2):187-191. doi:10.1093/jamia/ocx057. ht…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41967/psn-pdf
    May 10, 2013 - A comparative review of patient safety initiatives for national health information technology. May 10, 2013 Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health information technology. Int J Med Inform. 2013;82(5):e139-48. doi:10.1016/j.ijmedinf.2012.11.014. htt…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44427/psn-pdf
    October 13, 2015 - Problem list completeness in electronic health records: a multi-site study and assessment of success factors. October 13, 2015 Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi- site study and assessment of success factors. Int J Med Inform. 2015;84(10):784-90.…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60248/psn-pdf
    April 22, 2020 - Circumstances involved in unsupervised solid dose medication exposures among young children. April 22, 2020 Agarwal M, Lovegrove MC, Geller RJ, et al. Circumstances involved in unsupervised solid dose medication exposures among young children. J Pediatr. 2020;219. doi:10.1016/j.jpeds.2019.12.027. https://psnet.ahr…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41446/psn-pdf
    June 13, 2012 - Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized provider order entry: a tool for quality improvement and hospital risk management. June 13, 2012 Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal laborator…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43590/psn-pdf
    October 08, 2014 - Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. October 8, 2014 Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal, comparative study of hand …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40946/psn-pdf
    January 19, 2012 - Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project. January 19, 2012 Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad f…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47752/psn-pdf
    May 29, 2019 - How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. May 29, 2019 Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. Int …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41212/psn-pdf
    March 14, 2012 - A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. March 14, 2012 de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complain…

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