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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50425/psn-pdf
    September 04, 2019 - Why doctors still offer treatments that may not help. September 4, 2019 Frakt A. New York Times. August 26, 2019. https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44420/psn-pdf
    August 26, 2015 - Obstetric safety and quality. August 26, 2015 Pettker CM, Grobman WA. Obstetric Safety and Quality. Obstet Gynecol. 2015;126(1):196-206. doi:10.1097/AOG.0000000000000918. https://psnet.ahrq.gov/issue/obstetric-safety-and-quality Obstetric hospital admission has substantial potential for harm should something go wr…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47067/psn-pdf
    May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety is the top priority. May 16, 2018 O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018. https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority Leadership participation at the front lines can drive safety improvement work. …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43219/psn-pdf
    January 01, 2015 - Developing a reporting and tracking tool for nursing student errors and near misses. May 28, 2014 Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4. https://psnet.ahrq.gov/issue/developing-repor…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46963/psn-pdf
    April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47766/psn-pdf
    March 27, 2019 - Advancing the Safety of Acute Pain Management. March 27, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/advancing-safety-acute-pain-management Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46240/psn-pdf
    June 21, 2017 - Implementation of a modified bedside handoff for a postpartum unit. June 21, 2017 Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487. https://psnet.ahrq.gov/issue/implementation-modif…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45612/psn-pdf
    November 09, 2016 - Pharmacist work stress and learning from quality related events. November 9, 2016 Boyle TA, Bishop A, Morrison B, et al. Pharmacist work stress and learning from quality related events. Res Social Adm Pharm. 2016;12(5):772-83. doi:10.1016/j.sapharm.2015.10.003. https://psnet.ahrq.gov/issue/pharmacist-work-stress-a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47336/psn-pdf
    March 04, 2019 - "Saying sorry": some strategies for effective apology within the workplace. March 4, 2019 Cleary M, Lees D, Lopez V. "Saying sorry": some strategies for effective apology within the workplace. Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571. https://psnet.ahrq.gov/issue/saying-sorry…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44871/psn-pdf
    April 22, 2016 - Making checklists work: South Carolina's statewide experiment. April 22, 2016 Rice S. MAKING CHECKLISTS WORK. Modern healthcare. 2016;46(4):14-6. https://psnet.ahrq.gov/issue/making-checklists-work-south-carolinas-statewide-experiment Although checklist implementation as a safety strategy has achieved some success…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45531/psn-pdf
    December 14, 2016 - The role of safety culture in influencing provider perceptions of patient safety. December 14, 2016 Bishop A, Boyle TA. The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety. J Patient Saf. 2016;12(4):204-209. https://psnet.ahrq.gov/issue/role-safety-culture-influencing-provider-percepti…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45565/psn-pdf
    May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. May 24, 2017 Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an undeniable role in sust…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73894/psn-pdf
    February 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief. February 22, 2022 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.  https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis Diagnostic errors remain an o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48068/psn-pdf
    June 12, 2019 - Health Professions Education. June 12, 2019 Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185. https://psnet.ahrq.gov/issue/health-professions-education Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue explores an overarching approac…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60040/psn-pdf
    March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital Complaints. March 11, 2020 Newcastle upon Tyne, UK: Healthwatch; January 2020. https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints Organizations need to do more than report and collect complaint data to realize improvements based on what is…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48067/psn-pdf
    June 12, 2019 - Maternal sleepiness and risk of infant drops in the postpartum period. June 12, 2019 Bittle MD, Knapp H, Polomano RC, et al. Maternal Sleepiness and Risk of Infant Drops in the Postpartum Period. Jt Comm J Qual Patient Saf. 2019;45(5):337-347. doi:10.1016/j.jcjq.2018.12.001. https://psnet.ahrq.gov/issue/maternal-s…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60975/psn-pdf
    September 30, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction. September 30, 2020 Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020. AHRQ Publication No. 20-0040-3-EF. https://psnet.ahrq.gov/issue/evidence-use-clinical-reasoning-checklists-diagnostic…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72559/psn-pdf
    December 09, 2020 - The Life and Death of Elizabeth Dixon: A Catalyst for Change. December 9, 2020 Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714. https://psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change Missed diagnosis of a dangerous condition in utero, treatment errors, lack of respons…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46199/psn-pdf
    September 27, 2017 - The development and implementation of checklists in obstetrics. September 27, 2017 Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032. https://psnet.ahrq.gov/issue/development-and-i…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34648/psn-pdf
    April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…

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