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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47167/psn-pdf
    May 30, 2018 - AHRQ Health Information Technology Division's 2017 Annual Report. May 30, 2018 Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028- EF. https://psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report Health care has worked to enhance use…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44821/psn-pdf
    December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. December 5, 2022 Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011. https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture Im…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44597/psn-pdf
    October 28, 2015 - Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance. October 28, 2015 Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352. https://psnet.ahrq.gov/…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47200/psn-pdf
    August 20, 2018 - Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit. August 20, 2018 Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175. https://psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-har…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44651/psn-pdf
    December 09, 2015 - Measurement of diagnostic errors is a key first step to their reduction. December 9, 2015 Singh H. National Quality Measures Expert Commentaries. November 23, 2015. https://psnet.ahrq.gov/issue/measurement-diagnostic-errors-key-first-step-their-reduction Recently, diagnostic error has garnered much discussion and …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45812/psn-pdf
    June 22, 2017 - A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. June 22, 2017 Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245. https://psnet.ahrq.gov/issue/primer-pdsa-execu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46938/psn-pdf
    April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse practitioners. April 25, 2018 Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ. 2018;57(4):203-208. doi:10.3928/01484834-20180322-03. https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44911/psn-pdf
    February 17, 2016 - Improving doctor–patient communication in a digital world. February 17, 2016 Lakshmanan I. The Diane Rehm Show. February 9, 2016. https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world Digital technologies represent both promise and risks for communication in health care. This radio inte…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45034/psn-pdf
    February 25, 2019 - Future directions for diagnostic decision support. February 25, 2019 Carr S. ImproveDx. April 2016;3:1-3. https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic accuracy. This newsletter article …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47377/psn-pdf
    February 20, 2019 - Every patient should be enabled to stop the line. February 20, 2019 Bell SK, Martinez W. Every patient should be enabled to stop the line. BMJ Qual Saf. 2019;28(3):172-176. doi:10.1136/bmjqs-2018-008714. https://psnet.ahrq.gov/issue/every-patient-should-be-enabled-stop-line The Toyota manufacturing model "stop the…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74710/psn-pdf
    January 26, 2022 - The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety. January 26, 2022 Warner MA, Warner ME. The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further i…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836758/psn-pdf
    March 16, 2022 - Internet of things in healthcare for patient safety: an empirical study. March 16, 2022 Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study. BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3. https://psnet.ahrq.gov/issue/internet-things-healthc…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48120/psn-pdf
    July 17, 2019 - 2018 John M. Eisenberg Patient Safety and Quality Awards. July 17, 2019 Jt Comm J Qual Patient Saf. 2019;45(7):461-486. https://psnet.ahrq.gov/issue/2018-john-m-eisenberg-patient-safety-and-quality-awards The Eisenberg Award honors individuals and organizations who have made important contributions to patient saf…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840167/psn-pdf
    November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation. November 16, 2022 Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759. https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44868/psn-pdf
    June 17, 2016 - Patient safety and the problem of many hands. June 17, 2016 Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232. https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands Although individual and organizational accountabi…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861769/psn-pdf
    January 31, 2024 - Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. January 31, 2024 McElroy C, Skegg E, Mudgway M, et al. Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. J Surg Res. 2023;295:567-573. doi:10.1016/j.jss.2023.11.054. https://psn…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44465/psn-pdf
    November 20, 2015 - Why even good physicians do not wash their hands. November 20, 2015 Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf. 2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319. https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands Insufficient hand hygiene comp…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47057/psn-pdf
    July 14, 2018 - A framework for operationalizing risk: a practical approach to patient safety.  July 14, 2018 Mathews SC, Sutcliffe K, Garrett MR, et al. A framework for operationalizing risk: A practical approach to patient safety. J Healthc Risk Manag. 2018;38(1):38-46. doi:10.1002/jhrm.21317. https://psnet.ahrq.gov/issue/frame…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44125/psn-pdf
    May 28, 2015 - AHRQ focuses on ambulatory patient safety. May 28, 2015 Ricciardi R. AHRQ Focuses on Ambulatory Patient Safety. J Nurs Care Qual. 2015;30(3):193-6. doi:10.1097/NCQ.0000000000000124. https://psnet.ahrq.gov/issue/ahrq-focuses-ambulatory-patient-safety AHRQ has generated funding and educational opportunities toward u…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46387/psn-pdf
    September 06, 2017 - A multicomponent fall prevention strategy reduces falls at an academic medical center. September 6, 2017 France D, Slayton J, Moore S, et al. A Multicomponent Fall Prevention Strategy Reduces Falls at an Academic Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2017;43(9). doi:10.1016/j.…

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