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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33568/psn-pdf
    June 15, 2024 - Root Cause Analysis June 15, 2024 Root Cause Analysis. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/root-cause-analysis PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed…
  2. psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
    August 22, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014  Also Read an Essay Citation Text: In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33737/psn-pdf
    September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce September 1, 2012 Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce Per…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50887/psn-pdf
    February 12, 2020 - Lessons learned from a systems approach to engaging patients and families in patient safety transformation. February 12, 2020 Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837848/psn-pdf
    August 17, 2022 - Health care quality and safety in a correctional system: creating goals and performance measures for improvement. August 17, 2022 Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating goals and performance measures for improvement. J Correct Health Care. 2022;28(…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44314/psn-pdf
    November 06, 2015 - Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study. November 6, 2015 Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854835/psn-pdf
    October 25, 2023 - Improving patient safety by shifting power from health professionals to patients. October 25, 2023 BMJ. 2023(383):2219, 2278, 2319, 2331. https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844989/psn-pdf
    February 22, 2023 - Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. February 22, 2023 White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. Expert Opin D…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45772/psn-pdf
    January 11, 2017 - Technical Series on Safer Primary Care. January 11, 2017 Geneva, Switzerland: World Health Organization; 2016. https://psnet.ahrq.gov/issue/technical-series-safer-primary-care Much of patient safety research has focused on the hospital setting, but a majority of health care is delivered in the ambulatory setting. …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41643/psn-pdf
    September 05, 2012 - A Randomized Field Study of a Leadership WalkRounds- Based Intervention. September 5, 2012 Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No. 12-113. https://psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention Leadership WalkRounds h…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45943/psn-pdf
    March 15, 2017 - Identifying and reducing complications after emergency room discharge. March 15, 2017 Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017. https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge Emergency departments are complex environments that harbor fac…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45570/psn-pdf
    December 07, 2016 - Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition. December 7, 2016 Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412. https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety- third-edition Engaging hospital lead…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38157/psn-pdf
    October 22, 2008 - Contributing factors identified by hospital incident report narratives. October 22, 2008 Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. https://psnet.ahrq.gov/issue/contributing-f…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45563/psn-pdf
    October 19, 2016 - Using a change model to reduce the risk of surgical site infection. October 19, 2016 Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949- 955. https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection Surgical site infections can resul…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60235/psn-pdf
    April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. April 15, 2020 NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020. https://psnet.ahrq.gov/issue/independent-morta…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35218/psn-pdf
    August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. August 7, 2018 Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety Created in 2001 to institute changes in he…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74758/psn-pdf
    February 09, 2022 - Emotional harm in the radiology department: analysis of an underrecognized preventable error. February 9, 2022 Siewert B, Swedeen S, Brook OR, et al. Emotional harm in the radiology department: analysis of an underrecognized preventable error. Radiology. 2022;302(3):613-619. doi:10.1148/radiol.2021211846. https://…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46579/psn-pdf
    April 11, 2018 - Electronic medicine can send you test results quickly. But what if they're scary? April 11, 2018 Boodman SG. Washington Post. March 26, 2018. https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary Although providing patients with access to physician notes and test r…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46844/psn-pdf
    March 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. March 7, 2018 Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212. doi:10.1377/hlthaff.2017.1144. https…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73065/psn-pdf
    March 24, 2021 - Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care. March 24, 2021 Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term car…

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