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8941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38341/psn-pdf
      April 02, 2009 - CPOE: it don't come easy. April 2, 2009 Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim. https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors…

8942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47053/psn-pdf
      May 23, 2018 - TeamSTEPPS Canada. May 23, 2018 Canadian Patient Safety Institute. https://psnet.ahrq.gov/issue/teamstepps-canada The TeamSTEPPS program was developed to support effective communication and teamwork skills in various health care settings. This site supports the Canadian TeamSTEPPS initiative. The program will pre…

8943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33902/psn-pdf
      December 22, 2014 - National Quality Measures Clearinghouse (NQMC). December 22, 2014 Agency for Healthcare Research and Quality. 1998-2018. https://psnet.ahrq.gov/issue/national-quality-measures-clearinghouse-nqmc This web-accessible database provided access to evidence-based quality measures and measure sets. The mission of the Nat…

8944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41411/psn-pdf
      October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE from FALLS. October 19, 2012 Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b. https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…

8945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40829/psn-pdf
      January 05, 2014 - Guide to Reducing Unintended Consequences of Electronic Health Records. January 5, 2014 Jones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. https://psnet.ahrq.gov/issue/guide-reducing-unintended-consequences-electronic-health-records …

8946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47556/psn-pdf
      November 28, 2018 - Improving Diagnosis. November 28, 2018 Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70. https://psnet.ahrq.gov/issue/improving-diagnosis This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, t…

8947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34138/psn-pdf
      January 20, 2016 - National Quality Forum. January 20, 2016 1099 14th Street NW, Suite 500, Washington DC 20005. https://psnet.ahrq.gov/issue/national-quality-forum The National Quality Forum (NQF) is a private, not-for-profit membership organization created to develop and implement a national strategy for quality and safety measure…

8948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50633/psn-pdf
      November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019. November 6, 2019 Washington DC: Leapfrog Group; 2019. https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019 Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in assessment to ensure their safety. This re…

8949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38446/psn-pdf
      May 07, 2014 - Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio. May 7, 2014 Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF. https://psnet.ahrq.gov/issue/inpatient-c…

8950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37318/psn-pdf
      January 04, 2012 - The meaning of justice in safety incident reporting. January 4, 2012 Weiner BJ, Hobgood C, Lewis MA. The meaning of justice in safety incident reporting. Soc Sci Med. 2008;66(2):403-13. https://psnet.ahrq.gov/issue/meaning-justice-safety-incident-reporting This article describes how the principles of just culture …

8951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38378/psn-pdf
      September 24, 2010 - I-CaRe: a case review tool focused on improving inpatient care. September 24, 2010 Lee JH, Vidyarthi A, Sehgal NL, et al. I-CaRe: a case review tool focused on improving inpatient care. Jt Comm J Qual Patient Saf. 2009;35(2):115-119, 61. https://psnet.ahrq.gov/issue/i-care-case-review-tool-focused-improving-inpati…

8952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42512/psn-pdf
      August 21, 2013 - Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. August 21, 2013 Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. doi:10.1002/jhm.2054. https://psnet.ahrq.gov/issue/project-…

8953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38908/psn-pdf
      January 03, 2017 - Rapid response systems in adult academic medical centers. January 3, 2017 Wood KA, Ranji SR, Ide B, et al. Rapid response systems in adult academic medical centers. Jt Comm J Qual Patient Saf. 2009;35(9):475-82, 437. https://psnet.ahrq.gov/issue/rapid-response-systems-adult-academic-medical-centers This survey ch…

8954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47352/psn-pdf
      February 13, 2019 - When is the surgeon too old to operate? February 13, 2019 Span P. New York Times. February 1, 2019. https://psnet.ahrq.gov/issue/when-surgeon-too-old-operate Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspa…

8955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34699/psn-pdf
      January 04, 2017 - Organizational costs of preventable medical errors. January 4, 2017 Weeks WB, Waldron J, Foster T, et al. The organizational costs of preventable medical errors. Jt Comm J Qual Improv. 2001;27(10):533-9. https://psnet.ahrq.gov/issue/organizational-costs-preventable-medical-errors Using two composite case studies a…

8956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41431/psn-pdf
      June 06, 2012 - First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety. June 6, 2012 Koppel R, Gordon S, ed. Ithaca, NY: Cornell University Press; 2012. ISBN: 9780801450778. https://psnet.ahrq.gov/issue/first-do-less-harm-confronting-inconvenient-problems-patient-safety This publication examines patient safe…

8957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40795/psn-pdf
      March 04, 2015 - Patient safety event reporting in a large radiology department. March 4, 2015 Schultz SR, Watson RE, Prescott SL, et al. Patient Safety Event Reporting in a Large Radiology Department. American Journal of Roentgenology. 2011;197(3). doi:10.2214/ajr.11.6718. https://psnet.ahrq.gov/issue/patient-safety-event-reporti…

8958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42757/psn-pdf
      November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector. November 20, 2013 Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013. https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector Following the implementation of a large clinical information communicati…

8959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41729/psn-pdf
      October 10, 2012 - Checklists change communication about key elements of patient care. October 10, 2012 Newkirk M, Pamplin JC, Kuwamoto R, et al. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. doi:10.1097/TA.0b013e3182606239. https://psnet.ahrq.gov/issue/check…

8960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41836/psn-pdf
      November 14, 2012 - "Team time-out" and surgical safety—experiences in 12,390 neurosurgical patients. November 14, 2012 Oszvald Á, Vatter H, Byhahn C, et al. “Team time-out” and surgical safety—experiences in 12,390 neurosurgical patients. Neurosurg Focus. 2012;33(5). doi:10.3171/2012.8.focus12261. https://psnet.ahrq.gov/issue/team-t…