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  1. psnet.ahrq.gov/web-mm/workaround-error
    October 30, 2024 - Workaround Error Citation Text: Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  2. psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  4. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
    May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33876/psn-pdf
    August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33698/psn-pdf
    August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010 In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pe…
  7. psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
    December 15, 2024 - Medication Errors and Adverse Drug Events Citation Text: Medication Errors and Adverse Drug Events. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73303/psn-pdf
    May 26, 2021 - Safety Culture in EMS May 26, 2021 Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/safety-culture-ems Defining a Just Culture A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an environmen…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33872/psn-pdf
    January 01, 2018 - Update: Patient Engagement in Safety January 1, 2018 Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/update-patient-engagement-safety Annual Perspective 2018 Background Patient engagement has become a cornerstone of patient safety. A Patient Saf…
  10. psnet.ahrq.gov/primer/reporting-patient-safety-events
    March 30, 2022 - Reporting Patient Safety Events Citation Text: Reporting Patient Safety Events. 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 tagge…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44568/psn-pdf
    October 21, 2015 - Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. October 21, 2015 Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. J…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73622/psn-pdf
    August 25, 2021 - The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. August 25, 2021 Grailey KE, Murray E, Reader T, et al. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773. doi:10.1…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61068/psn-pdf
    October 28, 2020 - Are dental patients concerned about safety? An exploratory study. October 28, 2020 Obadan-Udoh E, Panwar S, Yansane A-I, et al. Are dental patients concerned about safety? An exploratory study. J Evid Based Dent Pract. 2020;20(3):101424. doi:10.1016/j.jebdp.2020.101424. https://psnet.ahrq.gov/issue/are-dental-pati…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73986/psn-pdf
    October 20, 2021 - Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project. October 20, 2021 Lamming L, Montague J, Crosswaite K, et al. Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the H…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72650/psn-pdf
    January 20, 2021 - A roadmap to advance patient safety in ambulatory care. January 20, 2021 Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481- 2482. doi:10.1001/jama.2020.18551. https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care Preventable harm, such as diag…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72814/psn-pdf
    March 10, 2021 - Implementing a human factors approach to RCA(2) : tools, processes and strategies. March 10, 2021 Wiegmann DA, Wood LJ, Solomon DB, et al. Implementing a human factors approach to RCA(2) : tools, processes and strategies. J Healthc Risk Manag. 2021;41(1):31-46. doi:10.1002/jhrm.21454. https://psnet.ahrq.gov/issue/…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846448/psn-pdf
    March 22, 2023 - Understanding patient and clinician reported nonroutine events in ambulatory surgery. March 22, 2023 Salwei ME, Anders S, Slagle JM, et al. Understanding patient and clinician reported nonroutine events in ambulatory surgery. J Patient Saf. 2023;19(2):e38-e45. doi:10.1097/pts.0000000000001089. https://psnet.ahrq.g…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854635/psn-pdf
    January 01, 2024 - CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. October 18, 2023 Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136/bmjqs-2023-016030. https://psn…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46116/psn-pdf
    May 24, 2017 - Elimination of emergency department medication errors due to estimated weights. May 24, 2017 Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5476. https://psnet.ahrq.gov/issue/elimin…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47239/psn-pdf
    October 24, 2018 - Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis. October 24, 2018 Lee SE, Vincent C, Dahinten S, et al. Effects of Individual Nurse and Hospital Characteristics on Patient Adverse Events and Quality of Care: A Multilevel Analysis. J Nurs…

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