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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44919/psn-pdf
    March 30, 2016 - Rapid response teams improve outcomes—Part 1, Part 2, and Part 3. March 30, 2016 Intensive Care Med. 2016;42(4):591-601. https://psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3 This three-part commentary presents differing views on whether rapid response teams (RRTs) improve pa…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74114/psn-pdf
    November 24, 2021 - Addressing health care disparities by improving quality and safety. November 24, 2021 Sentinel Event Alert. Nov 10 2021;(64):1-7. https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety Health care disparities are emerging as a core patient safety issue. This alert introduces s…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43372/psn-pdf
    April 13, 2016 - A case for improving measurement of intraoperative iatrogenic injuries. April 13, 2016 Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries. JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237. https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45923/psn-pdf
    April 19, 2017 - Huddles and debriefings: improving communication on labor and delivery. April 19, 2017 McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006. https://psnet.ahrq.gov/issue/huddles-and-debriefings…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837593/psn-pdf
    June 29, 2022 - Adverse event reporting priorities: an integrative review. June 29, 2022 Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945. https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42161/psn-pdf
    April 03, 2013 - Positioning continuing education: boundaries and intersections between the domains continuing education, knowledge translation, patient safety and quality improvement. April 3, 2013 Kitto S, Bell M, Peller J, et al. Positioning continuing education: boundaries and intersections between the domains continuing educ…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34935/psn-pdf
    June 23, 2009 - Improving patient care. The cognitive psychology of missed diagnoses. June 23, 2009 Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120. https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses This case study de…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45642/psn-pdf
    November 09, 2016 - Rethinking medical ward quality. November 9, 2016 Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417. doi:10.1136/bmj.i5417. https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality Patient safety research and commentary often focus on specialized care processes rathe…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43701/psn-pdf
    July 03, 2016 - Blink or think: can further reflection improve initial diagnostic impressions? July 3, 2016 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. https://psnet.ahrq.gov/issue/blink-or-thi…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43022/psn-pdf
    May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. May 29, 2014 Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. https://psnet.ahrq.gov/issue/using-sim…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38363/psn-pdf
    February 23, 2009 - Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research. February 23, 2009 Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, and the Office for Human Research Prote…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46427/psn-pdf
    April 04, 2018 - Improving Diagnosis in Radiology—Progress and Proposals. April 4, 2018 Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191. https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46243/psn-pdf
    June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and Recovery. June 5, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit- based S…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46082/psn-pdf
    February 25, 2019 - The opioid crisis: can improving diagnosis help solve the problem? February 25, 2019 Carr S. ImproveDx. April 2017;4:1-4. https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can contr…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39042/psn-pdf
    July 13, 2010 - Global oximetry: an international anaesthesia quality improvement project. July 13, 2010 Walker IA, Merry AF, Wilson IH, et al. Global oximetry: an international anaesthesia quality improvement project. Anaesthesia. 2009;64(10):1051-60. doi:10.1111/j.1365-2044.2009.06067.x. https://psnet.ahrq.gov/issue/global-oxim…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865933/psn-pdf
    May 22, 2024 - Utilizing pharmacogenomic testing can improve medication safety and prevent harm. May 22, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4. https://psnet.ahrq.gov/issue/utilizing-pharmacogenomic-testing-can-improve-medication-safety-and- prevent-harm Pharmacogenomics (PGx) refers to the impact of gen…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  18. psnet.ahrq.gov/primer/communication-between-clinicians
    September 15, 2024 - Communication Between Clinicians Citation Text: Communication Between Clinicians. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  19. psnet.ahrq.gov/issue/wireless-technologies-and-patient-safety-hospitals
    August 30, 2023 - Review Wireless technologies and patient safety in hospitals. Citation Text: Boyle J. Wireless technologies and patient safety in hospitals. Telemed J E Health. 2006;12(3):373-82. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  20. psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
    July 19, 2023 - Commentary Kaiser Permanente's performance improvement system, part 4: creating a learning organization. Citation Text: Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…

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