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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43636/psn-pdf
    November 26, 2014 - Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery. November 26, 2014 Braham DL, Richardson AL, Malik IS. Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery. Clin Med. 2014;14(5):468-474. doi:1…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46057/psn-pdf
    September 24, 2017 - Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention. September 24, 2017 Alidina S, Hur H-C, Berry WR, et al. Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety che…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73112/psn-pdf
    April 07, 2021 - Smartphone distraction during nursing care: systematic literature review. April 7, 2021 Fiorinelli M, Di Mario S, Surace A, et al. Smartphone distraction during nursing care: systematic literature review. Appl Nurs Res. 2021;58:151405. doi:10.1016/j.apnr.2021.151405. https://psnet.ahrq.gov/issue/smartphone-distrac…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73575/psn-pdf
    August 04, 2021 - Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. August 4, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.  https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs Lack of appropriate follow up o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39707/psn-pdf
    January 07, 2015 - Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests. January 7, 2015 Lighthall GK, Parast L, Rapoport L, et al. Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests. Anesth Analg. 2010;111(3):679-86. do…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46922/psn-pdf
    January 01, 2019 - Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project. March 21, 2018 Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/pq9.0000000000000053. https://ps…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42002/psn-pdf
    May 10, 2013 - National efforts to improve health information system safety in Canada, the United States of America and England. May 10, 2013 Kushniruk AW, Bates DW, Bainbridge M, et al. National efforts to improve health information system safety in Canada, the United States of America and England. Int J Med Inform. 2013;82(5):…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44320/psn-pdf
    October 28, 2015 - Interventions for reducing medication errors in children in hospital. October 28, 2015 Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3. https://psnet.ahrq.gov/issue/int…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73589/psn-pdf
    August 11, 2021 - Suicide and suicide attempts on hospital grounds and clinic areas. August 11, 2021 Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356. https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39773/psn-pdf
    August 18, 2010 - Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. August 18, 2010 Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order e…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45298/psn-pdf
    April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417- 422. doi:10.1136/bmjqs-2016-005511. https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to investigate incident…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72708/psn-pdf
    February 03, 2021 - How communication "failed" or "saved the day": counterfactual accounts of medical errors. February 3, 2021 Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1177/2374373520925270. https://p…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36734/psn-pdf
    March 10, 2011 - Integrating incident reporting into an electronic patient record system. March 10, 2011 Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assoc. 2007;14(2):175-81. https://psnet.ahrq.gov/issue/integrating-incident-reporting-electronic…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43469/psn-pdf
    August 27, 2014 - Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis. August 27, 2014 Gillespie BM, Chaboyer W, Thalib L, et al. Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis. Anesthesiology. 2014;120(6):1…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38174/psn-pdf
    November 05, 2008 - National Surgical Quality Improvement Program. November 5, 2008 American College of Surgeons. https://psnet.ahrq.gov/issue/national-surgical-quality-improvement-program During the 1980s, the Department of Veterans Affairs (VA) received significant public scrutiny over the quality of surgical care in their hospital…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39859/psn-pdf
    November 21, 2016 - Experience with family activation of rapid response teams. November 21, 2016 Bogert S, Ferrell C, Rutledge DN. Experience with family activation of rapid response teams. Medsurg Nurs. 2010;19(4):215-22; quiz 223. https://psnet.ahrq.gov/issue/experience-family-activation-rapid-response-teams The central tenet behi…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850353/psn-pdf
    June 14, 2023 - Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review. June 14, 2023 Sparling J, Hong Mershon B, Abraham J. Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review. Jt Comm J Qual Patient Saf. 20…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74871/psn-pdf
    October 01, 2023 - AHRQ Safety Program for MRSA Prevention. February 14, 2023 Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023. https://psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. Thi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867643/psn-pdf
    February 26, 2025 - Psychology insights on apologizing to patients. February 26, 2025 Redelmeier DA, Roach J. Psychology insights on apologizing to patients. J Hosp Med. 2024;Epub Dec 30. doi:10.1002/jhm.13585. https://psnet.ahrq.gov/issue/psychology-insights-apologizing-patients Apologizing to the patient and family after a harmful …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40736/psn-pdf
    January 04, 2012 - Preventing wrong site, procedure, and patient events using a common cause analysis. January 4, 2012 Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/1062860611412066. https://psnet.ahrq.gov/issue/p…

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