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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46753/psn-pdf
    January 30, 2018 - Leadership oversight for patient safety programs: an essential element. January 30, 2018 Moffatt-Bruce SD, Clark S, DiMaio M, et al. Leadership Oversight for Patient Safety Programs: An Essential Element. Ann Thorac Surg. 2017;105(2):351-356. doi:10.1016/j.athoracsur.2017.11.021. https://psnet.ahrq.gov/issue/leade…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45094/psn-pdf
    May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. May 4, 2016 Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16- 328. https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care This analysis found that s…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46386/psn-pdf
    April 03, 2018 - The impact of electronic health records on diagnosis. April 3, 2018 Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl). 2017;4(4):211-223. doi:10.1515/dx-2017-0012. https://psnet.ahrq.gov/issue/impact-electronic-health-records-diagnosis Health information technol…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839825/psn-pdf
    November 09, 2022 - Preventing medication errors in pediatric anesthesia: a systematic scoping review. November 9, 2022 Shawahna R, Jaber M, Jumaa E, et al. Preventing medication errors in pediatric anesthesia: a systematic scoping review. J Patient Saf. 2022;18(7):e1047-e1060. doi:10.1097/pts.0000000000001019. https://psnet.ahrq.gov…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43943/psn-pdf
    December 04, 2015 - Culture Change in the NHS: Applying the Lessons of the Francis Inquiries. December 4, 2015 Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116. https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries The Francis inquiry uncovered numerous problems …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47408/psn-pdf
    September 19, 2018 - Ways to Improve Electronic Health Record Safety. September 19, 2018 Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018. https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety Electronic health records both contribute to and detract from safe care. This…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73077/psn-pdf
    March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44674/psn-pdf
    December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. December 18, 2017 Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390. https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health Since the publication of the Inst…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46551/psn-pdf
    October 25, 2017 - Inpatient notes: diagnostic excellence starts with an incessant watch. October 25, 2017 Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447. https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867655/psn-pdf
    February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…
  11. psnet.ahrq.gov/issue/pharmacist-medication-reviews-improve-safety-monitoring-primary-care-patients
    April 24, 2018 - Study Pharmacist medication reviews to improve safety monitoring in primary care patients. Citation Text: Gallimore CE, Sokhal D, Schreiter EZ, et al. Pharmacist medication reviews to improve safety monitoring in primary care patients. Fam Syst Health. 2016;34(2):104-113. doi:10.1037/fsh…
  12. psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors
    May 29, 2019 - Study Improving radiology report quality by rapidly notifying radiologist of report errors. Citation Text: Minn MJ, Zandieh AR, Filice RW. Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors. J Digit Imaging. 2015;28(4):492-8. doi:10.1007/s10278-015-9781-…
  13. psnet.ahrq.gov/issue/feedback-incident-reporting-information-and-action-improve-patient-safety
    August 26, 2009 - Study Feedback from incident reporting: information and action to improve patient safety. Citation Text: Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18(1):11-21. doi:10.1136/qshc.2…
  14. psnet.ahrq.gov/issue/reducing-retained-foreign-objects-operating-room-quality-improvement-initiative
    April 19, 2023 - Study Reducing retained foreign objects in the operating room: a quality improvement initiative. Citation Text: Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.10…
  15. psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-reduce-errors
    February 04, 2015 - Commentary Using morbidity and mortality conferences to drive quality improvement and reduce errors. Citation Text: Using morbidity and mortality conferences to drive quality improvement and reduce errors. Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17. Copy Cit…
  16. psnet.ahrq.gov/issue/education-service-partnership-achieve-safety-and-quality-improvement-competencies-nursing
    August 30, 2023 - Commentary An education-service partnership to achieve safety and quality improvement competencies in nursing. Citation Text: Fater KH, Ready R. An Education-Service Partnership to Achieve Safety and Quality Improvement Competencies in Nursing. Journal of Nursing Education. 2011;50(12).…
  17. psnet.ahrq.gov/issue/teaching-structured-tool-improves-clarity-and-content-interprofessional-clinical
    June 28, 2017 - Study The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Citation Text: Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual …
  18. psnet.ahrq.gov/issue/strategies-improving-patient-safety-linking-task-type-error-type
    August 22, 2012 - Commentary Strategies for improving patient safety: linking task type to error type. Citation Text: Mattox EA. Strategies for improving patient safety: linking task type to error type. Crit Care Nurse. 2012;32(1):52-78. doi:10.4037/ccn2012303. Copy Citation Format: DOI Go…
  19. psnet.ahrq.gov/issue/blink-or-think-can-further-reflection-improve-initial-diagnostic-impressions
    November 28, 2012 - Study Blink or think: can further reflection improve initial diagnostic impressions? Citation Text: Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550. Copy…
  20. psnet.ahrq.gov/issue/just-culture-improving-safety-achieving-substantive-procedural-and-restorative-justice
    October 19, 2022 - Commentary 'Just culture': improving safety by achieving substantive, procedural and restorative justice. Citation Text: Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.…

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