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6781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861762/psn-pdf
      January 31, 2024 - Responding to medical errors — implementing the modern ethical paradigm. January 31, 2024 Gallagher TH, Kachalia A. Responding to medical errors — implementing the modern ethical paradigm. New Engl J Med. 2024;390(3):193-197. doi:10.1056/nejmp2309554. https://psnet.ahrq.gov/issue/responding-medical-errors-implemen…

6782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47420/psn-pdf
      January 01, 2019 - Gross negligence manslaughter and doctors: ethical concerns following the case of Dr Bawa-Garba. December 21, 2018 Samanta A, Samanta J. Gross negligence manslaughter and doctors: ethical concerns following the case of Dr Bawa-Garba. J Med Ethics. 2019;45(1):10-14. doi:10.1136/medethics-2018-104938. https://psnet.…

6783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74722/psn-pdf
      February 02, 2022 - Preventing and mitigating radiology system failures: a guide to disaster planning. February 2, 2022 Gibney BT, Roberts JM, D'Ortenzio RM, et al. Preventing and mitigating radiology system failures: a guide to disaster planning. RadioGraphics. 2021;41(7):2111-2126. doi:10.1148/rg.2021210083. https://psnet.ahrq.gov/…

6784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38099/psn-pdf
      October 01, 2008 - Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek. October 1, 2008 Yaghoubian A, Saltmarsh G, Rosing DK, et al. Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek. Arch Surg. 2008;143(9):847-5…

6785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46137/psn-pdf
      August 03, 2017 - Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. August 3, 2017 Schulz CM, Burden A, Posner KL, et al. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology. 2017;127(2)…

6786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46258/psn-pdf
      January 01, 2021 - Development of a trigger tool to identify adverse drug events in elderly patients with multimorbidity. August 30, 2017 Guzmán MDT, Banqueri MG, Otero MJ, et al. Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity. J Patient Saf. 2021;17(6):e475-e482. doi:10.1097/PT…

6787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44584/psn-pdf
      March 15, 2016 - Barriers to implementing a reporting and learning patient safety system: pediatric chiropractic perspective. March 15, 2016 Pohlman KA, Carroll L, Hartling L, et al. Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective. J Evid Based Complementary Altern Med. 20…

6788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46501/psn-pdf
      March 20, 2018 - Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. March 20, 2018 Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104. https://psnet.ahrq.gov/issue/blind…

6789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842759/psn-pdf
      January 18, 2023 - Cognitive aids in the management of clinical emergencies: a systematic review. January 18, 2023 Greig PR, Zolger D, Onwochei DN, et al. Cognitive aids in the management of clinical emergencies: a systematic review. Anaesthesia. 2023;78(3):343-355. doi:10.1111/anae.15939. https://psnet.ahrq.gov/issue/cognitive-aids…

6790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42329/psn-pdf
      December 18, 2014 - Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. December 18, 2014 Chandonnet CJ, Kahlon PS, Rachh P, et al. Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. Pediatrics. 2013;131(6):e1961-9. doi:10.1542/peds.2012-3…

6791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37156/psn-pdf
      October 06, 2011 - Preventable harm occurring to critically ill children. October 6, 2011 Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit Care Med. 2007;8(4):331-336. https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children This retrospective cohort…

6792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46028/psn-pdf
      July 05, 2017 - The role of morbidity and mortality rounds in medical education: a scoping review. July 5, 2017 Benassi P, MacGillivray L, Silver I, et al. The role of morbidity and mortality rounds in medical education: a scoping review. Med Educ. 2017;51(5):469-479. doi:10.1111/medu.13234. https://psnet.ahrq.gov/issue/role-morb…

6793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39121/psn-pdf
      March 04, 2011 - The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. March 4, 2011 van Doormaal J, van den Bemt PMLA, Zaal RJ, et al. The influence that electronic prescribing has on medication errors and preventable adverse drug events: an inter…

6794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47459/psn-pdf
      October 10, 2018 - People, processes, health IT and accurate patient identification. October 10, 2018 Quick Safety. October 1, 2018;(45):1-2. https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification This newsletter article reviews common problems related to patient identification and recommends st…

6795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46479/psn-pdf
      October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts. October 4, 2017 Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395. https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts Applying evidence generated from complaints submitted to h…

6796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47393/psn-pdf
      November 28, 2018 - Still Failing the Frail. November 28, 2018 Simmons-Ritchie D. Penn Live. November 15, 2018. https://psnet.ahrq.gov/issue/still-failing-frail Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial in…

6797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42919/psn-pdf
      February 05, 2014 - Implementing hospital-based communication-and- resolution programs: lessons learned in New York City. February 5, 2014 Mello MM, Senecal SK, Kuznetsov Y, et al. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Health Aff (Millwood). 2014;33(1):30-8. doi:10.1377/h…

6798. Final Progress Report: Analyzing Nurses’ Impact on Outcomes Using Detailed Data (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/harris-report.pdf
      January 01, 2024 - Final Progress Report: Analyzing Nurses’ Impact on Outcomes Using Detailed Data Analyzing Nurses’ Impact on Outcomes Using Detailed Data Principal Investigator Marcelline R. Harris, PhD Mayo Clinic 200 1st St SW Rochester MN 55905 Team Members Mayo Clinic V. Shane Pankratz, PhD Cynthia Leibson…

6799. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. | PSNet
      psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
      October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

6800. Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2011
      January 01, 2011 - Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 Project Name Evaluation of AHRQ's On-time Pressure Ulcer Program Principal Investigator Hurd, Donna Organization Abt Associates, Inc. Contract Number 290-06-0011-8 Project Period June 2009 - January …