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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854385/psn-pdfOctober 11, 2023 - Perioperative team-based morbidity and mortality conferences: a systematic review of the literature. October 11, 2023 Samost-Williams A, Rosen R, Hannenberg A, et al. Perioperative team-based morbidity and mortality conferences: a systematic review of the literature. Ann Surg Open. 2023;4(3):e321. doi:10.1097/as9.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45152/psn-pdfNovember 18, 2016 - Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change. November 18, 2016 Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: A Model to Spread Change. Am J Med Qual. 2016;31(6):598-600. h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73067/psn-pdfMarch 24, 2021 - Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021 LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866959/psn-pdfOctober 16, 2024 - A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. October 16, 2024 Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in Swedish healthcare to characteris… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72790/psn-pdfMarch 03, 2021 - Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries. March 3, 2021 Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836715/psn-pdfMarch 09, 2022 - Non-technical skills in surgery during the COVID-19 pandemic: an observational study. March 9, 2022 Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Non-technical skills in surgery during the COVID-19 pandemic: an observational study. Int J Surg. 2022;98:106210. doi:10.1016/j.ijsu.2021.106210. https://psnet.ahrq.gov/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46142/psn-pdfJune 14, 2017 - Introducing a new junior doctor electronic weekend handover on an orthopaedic ward. June 14, 2017 Maroo S, Raj D. Introducing a New Junior Doctor Electronic Weekend Handover on an Orthopaedic Ward. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u212695.w5059. https://psnet.ahrq.gov/issue/introducing-new-ju… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45960/psn-pdfJanuary 01, 2021 - Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. March 15, 2017 Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3):e121-e127. doi:10.1097/PTS.000000… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73211/psn-pdfMay 05, 2021 - The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety. May 5, 2021 Cerqueira O, Gill M, Swar B, et al. The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety. BMJ Qual Saf. 2021;30… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40191/psn-pdfMay 28, 2014 - The Value of Close Calls in Improving Patient Safety. May 28, 2014 Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety Close calls (sometimes called near misses) pose unique challenges and opportunities when … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/849610/psn-pdfMay 31, 2023 - Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. May 31, 2023 Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. J Healthc Qual. 2023;45(3):140-147. doi:10.1097/jhq.0000000000000374.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46467/psn-pdfOctober 18, 2017 - The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. October 18, 2017 Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46606/psn-pdfJuly 10, 2019 - Implementation of a mock root cause analysis to provide simulated patient safety training. July 10, 2019 Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-2017-000096. https://psnet.ahrq.gov/iss… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/857581/psn-pdfJanuary 01, 2025 - Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long- Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes. Au… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46739/psn-pdfJanuary 24, 2019 - Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. January 24, 2019 Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodologica… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47380/psn-pdfSeptember 05, 2018 - Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare. September 5, 2018 Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in healthcare. J Patient Saf Risk Mana… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866109/psn-pdfJune 12, 2024 - Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. June 12, 2024 Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. BMJ Open Qual. 2024… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867751/psn-pdfMarch 12, 2025 - Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers. March 12, 2025 Mahajan P, White E, Shaw KN, et al. Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers. Acad Emerg Med. 2025;Epub Jan 15. doi:10.1111/acem.15087. https://psnet.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861774/psn-pdfJanuary 31, 2024 - Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. January 31, 2024 Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866595/psn-pdfAugust 28, 2024 - Implementation, Adoption, and Scaling Workgroup: Landscape Assessment on the Use of Artificial Intelligence to Scale PC CDS. August 28, 2024 Kawamoto K, Greysen SR, Heaney-Huls K, et al. Implementation, Adoption, And Scaling Workgroup: Landscape Assessment On The Use Of Artificial Intelligence To Scale Pc Cds. Roc…
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