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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42931/psn-pdf
    April 20, 2014 - Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. April 20, 2014 Shieh L, Chi J, Kulik C, et al. Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. Jt Comm J Qual Patient Saf. 2014;40(2):77-82. https://psnet.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46374/psn-pdf
    August 30, 2017 - Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit. August 30, 2017 Hamilton WL. https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction- perioperative-unit Miscommunication during care transitions can contribute to medical e…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866160/psn-pdf
    June 19, 2024 - Checking all the boxes: a checklist for when and how to use checklists effectively. June 19, 2024 Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bmjqs-2023-016934. https://psnet.ahrq.gov…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47601/psn-pdf
    December 21, 2018 - Clinical decision support in the era of artificial intelligence. December 21, 2018 Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA. 2018;320(21):2199-2200. doi:10.1001/jama.2018.17163. https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34982/psn-pdf
    July 14, 2010 - Development of the ICU safety reporting system. July 14, 2010 Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32. https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. T…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863757/psn-pdf
    March 06, 2024 - Debriefing to improve interprofessional teamwork in the operating room: a systematic review. March 6, 2024 Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924. https://psnet.…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46866/psn-pdf
    May 23, 2018 - Improving maternal safety at scale with the mentor model of collaborative improvement. May 23, 2018 Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259. doi:10.1016/j.jcjq.2017.11.005. https://psn…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48045/psn-pdf
    June 05, 2019 - Obstetric practice guidelines: labor's love lost? June 5, 2019 Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474. https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost Guidelines play a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46901/psn-pdf
    May 30, 2018 - Physician resiliency and wellness for transforming a health system. May 30, 2018 Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018. https://psnet.ahrq.gov/issue/physician-resiliency-and-wellness-transforming-health-system Physician burnout can contribute to medical errors. This article discusses an organizational e…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45234/psn-pdf
    November 18, 2016 - Recommended responsibilities for management of MR safety. November 18, 2016 Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282. https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40305/psn-pdf
    March 23, 2011 - Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. March 23, 2011 Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204(2):97-105. doi:10.1016/…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40672/psn-pdf
    September 03, 2011 - Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. September 3, 2011 Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Pat…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42116/psn-pdf
    March 20, 2013 - Rapid response systems as a patient safety strategy: a systematic review. March 20, 2013 Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051-00009. https://psnet.ahrq.gov/issu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34061/psn-pdf
    January 04, 2017 - Patient Safety Leadership WalkRounds. January 4, 2017 Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1). doi:10.1016/s1549-3741(03)29003-1. https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds This study shares the concept of an interventi…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43967/psn-pdf
    November 16, 2015 - Equipped: overcoming barriers to change to improve quality of care (theories of change). November 16, 2015 Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-8. doi:10.1136/archdischild-2013- …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867700/psn-pdf
    March 01, 2023 - Toolkit for Reducing Central Line-Associated Blood Stream Infections. March 1, 2023 Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream Infections. March 2023. https://psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections Eliminatin…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72828/psn-pdf
    March 10, 2021 - A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021 ISMP Medication Safety Alert! Acute care edition. February 25, 2021;26(4);1-4. https://psnet.ahrq.gov/issue/recurring-call-action-every-healthcare-organization-needs-medication-safety- officer Leadership ro…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848383/psn-pdf
    May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in Your Practice. May 3, 2023 Gerteis J, Booker C, Brach C, et al. Rockville, MD:  Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025. https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60929/psn-pdf
    September 16, 2020 - Safer Together: A National Action Plan to Advance Patient Safety. September 16, 2020 Boston, MA: Institute for Healthcare Improvement: September 2020.   https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety This National Action Plan developed by the National Steering Committee for Pati…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34715/psn-pdf
    February 18, 2011 - Continuous improvement as an ideal in health care. February 18, 2011 Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56. https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care Two approaches to improving quality in health care are illustrated in this artic…

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