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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44867/psn-pdf
    March 23, 2016 - Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective. March 23, 2016 Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333. https://psnet.ahrq.gov/issue/understand…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72501/psn-pdf
    November 25, 2020 - Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. November 25, 2020 Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;29(21-22):4180-4193. doi:10.111…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47431/psn-pdf
    September 26, 2018 - Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. September 26, 2018 Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90. https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce- pr…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48180/psn-pdf
    August 21, 2019 - Burnout and Resilience and Quality and Safety Programs in Obstetrics and Gynecology. August 21, 2019 Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626. https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and- gynecology Obstetrics is a high-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43907/psn-pdf
    April 27, 2015 - Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. April 27, 2015 Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA. 2015;313…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46825/psn-pdf
    June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic errors using big data. June 19, 2018 Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945. https://psnet.ahrq.gov/issue/diagnosti…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46227/psn-pdf
    October 30, 2017 - Patient engagement with surgical site infection prevention: an expert panel perspective. October 30, 2017 Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3. …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47802/psn-pdf
    March 04, 2019 - The path to diagnostic excellence includes feedback to calibrate how clinicians think. March 4, 2019 Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113. https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853074/psn-pdf
    February 06, 2024 - Patient Experience, Patient Safety, and Provider Well- Being: Associations and Paths for Quality Improvement. February 6, 2024 Rockville, MD: Agency for Healthcare Research and Quality; January 2024. AHRQ Publication no. 24-0030. https://psnet.ahrq.gov/issue/patient-experience-patient-safety-and-provider-well…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43283/psn-pdf
    June 25, 2014 - Development, implementation, and dissemination of the I- PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs. June 25, 2014 Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I- PASS handoff curriculum: A multisite educational in…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48070/psn-pdf
    July 17, 2019 - Controversies in diagnosis: contemporary debates in the diagnostic safety literature. July 17, 2019 Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-2019-0016. https://psnet.ahrq.gov/issu…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45499/psn-pdf
    May 03, 2017 - Patient safety and interprofessional education: a report of key issues from two interprofessional workshops. May 3, 2017 Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from two interprofessional workshops. J Interprof Care. 2017;31(2):154-163. doi:10.1080/13561…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60060/psn-pdf
    March 18, 2020 - The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005. March 18, 2020 Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005. J Health Life Sc…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74856/psn-pdf
    February 23, 2022 - The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis. February 23, 2022 Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis. Ph…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73532/psn-pdf
    July 28, 2021 - The standardisation of handoffs in a large academic paediatric emergency department using I-PASS. July 28, 2021 Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e001254. doi:10.1136/bmjoq-2020- 001254.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47002/psn-pdf
    April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). April 25, 2018 Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750. https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care- facilities-r18 Research …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864371/psn-pdf
    March 13, 2024 - The ritualisation of the surgical safety checklist and its decoupling from patient safety goals. March 13, 2024 Facey M, Baxter NN, Hammond Mobilio M, et al. The ritualisation of the surgical safety checklist and its decoupling from patient safety goals. Sociol Health Illn. 2024;46(6):1100-1118. doi:10.1111/1467- …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60823/psn-pdf
    August 19, 2020 - Disaster ergonomics: human factors in COVID-19 pandemic emergency management. August 19, 2020 Sasangohar F, Moats J, Mehta R, et al. Disaster ergonomics: human factors in COVID-19 pandemic emergency management. Hum Factors. 2020;62(7):1061-1068. doi:10.1177/0018720820939428. https://psnet.ahrq.gov/issue/disaster-e…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. January 5, 2017 Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3. https://psnet.ah…

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