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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43012/psn-pdf
    January 07, 2016 - Uptake of quality-related event standards of practice by community pharmacies. January 7, 2016 Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066. https://psnet.ahrq.gov/issue/uptake-qua…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44053/psn-pdf
    November 16, 2015 - ANA CAUTI Prevention Tool. November 16, 2015 Silver Spring, MD: American Nurses Association; 2015. https://psnet.ahrq.gov/issue/ana-cauti-prevention-tool Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836999/psn-pdf
    April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs. April 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; April 2022. https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this cu…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42000/psn-pdf
    March 06, 2013 - Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. March 6, 2013 Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. Jt Comm J Qual Patient Saf. 2013;39(2):89-95. https://psnet…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34701/psn-pdf
    January 04, 2017 - Making the business case for patient safety. January 4, 2017 Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4, 1. https://psnet.ahrq.gov/issue/making-business-case-patient-safety While the costs of medical error to patients are well appreciated, the direct costs…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34659/psn-pdf
    April 07, 2010 - Leading change: why transformation efforts fail. April 7, 2010 Kotter JP. Harvard Bus Rev  1995;73(2);59-67. https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well a…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72835/psn-pdf
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33607/psn-pdf
    September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…
  11. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  12. psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
    April 12, 2023 - SPOTLIGHT CASE Triaging Interhospital Transfers Citation Text: Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX En…
  13. psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  14. psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  15. psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
    June 12, 2024 - Special or Theme Issue States Targeting Reduction in Infections via Engagement (STRIVE). Citation Text: States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171(7_Suppl):s1-s82. Copy Citation Save Save to your library Prin…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33562/psn-pdf
    September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems 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.…
  18. psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
    April 05, 2017 - Study Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative. Citation Text: Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
  19. psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - Instead of blaming the doctors, we have a systemic issue where the technology either wasn't selected or implemented
  20. psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
    February 10, 2021 - One healthcare system implemented an alert whenever a patient taking an anticoagulant or antiplatelet

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