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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48073/psn-pdf
    June 19, 2019 - Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. June 19, 2019 Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308. https://psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions- advance-surgical Surg…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46528/psn-pdf
    January 10, 2018 - Five Years of Experience Using Front-line Ownership to Improve Healthcare Quality and Safety. January 10, 2018 Healthc Pap. 2017;17:1-61. https://psnet.ahrq.gov/issue/five-years-experience-using-front-line-ownership-improve-healthcare-quality- and-safety Patient safety leaders have noted the need to recognize the…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43805/psn-pdf
    February 11, 2015 - Understanding the nature of medication errors in an ICU with a computerized physician order entry system. February 11, 2015 Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One. 2014;9(12):e114243. doi:10.1371/journal.pon…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47024/psn-pdf
    November 28, 2018 - FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management. November 28, 2018 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018. https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851917/psn-pdf
    January 01, 2024 - Incivility in healthcare: the impact of poor communication. August 2, 2023 Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead. 2024;8(1):83-87. doi:10.1136/leader-2022-000717. https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication Incivi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39264/psn-pdf
    February 03, 2010 - Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. February 3, 2010 Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. Crit Care Med. 2010;38(2):445…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37430/psn-pdf
    February 01, 2011 - Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. February 1, 2011 Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782. https://psnet.ahrq.gov/issue/…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38332/psn-pdf
    January 14, 2009 - Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. January 14, 2009 Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8. doi:10.11…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41515/psn-pdf
    July 02, 2014 - Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors. July 2, 2014 Shea JA, Willett LL, Borman KR, et al. Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors. Acad Med. 2012;87(7):895-903.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44952/psn-pdf
    March 02, 2016 - Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences. March 2, 2016 Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48034/psn-pdf
    May 22, 2019 - Chasing zero harm in radiation oncology: using pre- treatment peer review. May 22, 2019 Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre- treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302. https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60974/psn-pdf
    September 30, 2020 - Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic. September 30, 2020 London, UK: General Medical Council; September 14, 2020. https://psnet.ahrq.gov/issue/covid-19-assessing-risk-public-protection-posed-doctor-result-concerns-about…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39088/psn-pdf
    September 01, 2015 - Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors. September 1, 2015 Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medica…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43516/psn-pdf
    June 15, 2017 - Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department. June 15, 2017 Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through the Emergency Department. J Patient …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45857/psn-pdf
    July 11, 2017 - Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study. July 11, 2017 Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45138/psn-pdf
    May 25, 2016 - Improving Weekend Out Of Hours Surgical Handover (WOOSH). May 25, 2016 Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190. https://psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48018/psn-pdf
    July 31, 2019 - PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. July 31, 2019 Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342. doi:10.1097/SIH.0000000000…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37193/psn-pdf
    October 06, 2011 - Incomplete EHR adoption: late uptake of patient safety and cost control functions. October 6, 2011 Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost control functions. Am J Med Qual. 2007;22(5):319-26. https://psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-u…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43182/psn-pdf
    May 14, 2014 - Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome? May 14, 2014 Hagerman NS, Varughese AM, Kurth D. Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome? Curr Opin Anaesthesiol. 2014;27(3):323-9…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866642/psn-pdf
    September 04, 2024 - Learning from patient safety incidents: The Green Cross method. September 4, 2024 Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114. https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cro…

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