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5061. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836867/psn-pdf
      April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…

5062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35698/psn-pdf
      July 13, 2010 - Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science. July 13, 2010 Colón-Emeric CS, Ammarell N, Bailey D, et al. Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science. Qual Health R…

5063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41982/psn-pdf
      January 07, 2015 - Multitasking during patient handover in the recovery room. January 7, 2015 van Rensen ELJ, Groen EST, Numan SC, et al. Multitasking during patient handover in the recovery room. Anesth Analg. 2012;115(5):1183-7. doi:10.1213/ANE.0b013e31826996a2. https://psnet.ahrq.gov/issue/multitasking-during-patient-handover-rec…

5064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42518/psn-pdf
      January 07, 2015 - Role of computerized physician order entry usability in the reduction of prescribing errors. January 7, 2015 Peikari HR, Zakaria MS, Yasin NM, et al. Role of computerized physician order entry usability in the reduction of prescribing errors. Healthc Inform Res. 2013;19(2):93-101. doi:10.4258/hir.2013.19.2.93. htt…

5065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39915/psn-pdf
      December 18, 2014 - Improving the quality of discharge communication with an educational intervention. December 18, 2014 Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884. https://psnet.ahrq.gov/issue/im…

5066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43748/psn-pdf
      December 03, 2014 - New enteral connectors: raising awareness. December 3, 2014 Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5). doi:10.1177/0884533614543330. https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness Redesigning tubing connectors according to new ISO standards has the potenti…

5067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47318/psn-pdf
      October 12, 2018 - ISMP Survey on IV Push Medication Practices. October 12, 2018 Institute for Safe Medication Practices; ISMP. https://psnet.ahrq.gov/issue/ismp-survey-iv-push-medication-practices Errors in IV push medication use can cause patient harm. This survey seeks to gather data on how clinicians administer IV push medicatio…

5068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42979/psn-pdf
      March 05, 2014 - Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. March 5, 2014 Clinical Uncertainty In Primary Care. Springer New York; 2013. doi:10.1007/978-1-4614-6812-7. https://psnet.ahrq.gov/issue/clinical-uncertainty-primary-care-challenge-collaborative-engagement This book introduces the rol…

5069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46055/psn-pdf
      July 26, 2017 - Bridging the gap between work-as-imagined and work-as- done. July 26, 2017 Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83. https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done Understanding what is possible in the context of frontline practice is key when designing enhancements …

5070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35632/psn-pdf
      February 03, 2025 - Anesthesia Patient Safety Foundation (APSF) Grant Program. February 3, 2025 Anesthesia Patient Safety Foundation. https://psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-apsf-grant-program This grant program supports research that seeks to improve anesthesia safety and the development of researchers in …

5071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36260/psn-pdf
      May 27, 2011 - The effect of physicians' long-term use of CPOE on their test management work practices. May 27, 2011 Callen JL, Westbrook JI, Braithwaite J. The effect of physicians' long-term use of CPOE on their test management work practices. J Am Med Inform Assoc. 2006;13(6):643-52. https://psnet.ahrq.gov/issue/effect-physic…

5072. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36158/psn-pdf
      September 29, 2010 - Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare. September 29, 2010 Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9. https://psnet.ahrq.gov/issue/medicatio…

5073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34051/psn-pdf
      March 07, 2005 - A call to excellence. March 7, 2005 Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5. https://psnet.ahrq.gov/issue/call-excellence This commentary, written by leadership from the Agency for Healthcare and Research Quality (AHRQ) and the Centers for Medicare and Medicaid Services (…

5074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35083/psn-pdf
      March 29, 2007 - Patient Safety: Achieving a New Standard for Care. March 29, 2007 Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC: National Academies Press; 2004. ISBN 0309090776. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care This report details findings…

5075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46018/psn-pdf
      January 16, 2019 - Rethinking Patient Safety. January 16, 2019 Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541. https://psnet.ahrq.gov/issue/rethinking-patient-safety The National Health Service (NHS) has been a leader in patient safety work for close to two decades. This book draws from a large-scale impro…

5076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43371/psn-pdf
      June 19, 2019 - Medication Safety Officer's Handbook. June 19, 2019 Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104. https://psnet.ahrq.gov/issue/medication-safety-officers-handbook This book provides information about medication errors and quality improvement to gui…

5077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839832/psn-pdf
      November 09, 2022 - Diagnostic Safety Centers of Excellence. November 9, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. https://psnet.ahrq.gov/issue/diagnostic-safety-centers-excellence Diagnostic improvement engages a variety of activities to achieve excellence. This announcement highlights ten organiz…

5078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45311/psn-pdf
      May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd Edition. May 20, 2019 Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598. https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition Checklists are a widely accepted strategy to improve communication and standardize processes to su…

5079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34728/psn-pdf
      December 19, 2016 - Forgive and Remember: Managing Medical Failure. 2nd ed. December 19, 2016 Bosk CL.Chicago, IL: University of Chicago Press; 2003. ISBN: 9780226066783. https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed In this seminal study, Bosk, a medical sociologist at the University of Pennsylvan…

5080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61031/psn-pdf
      October 14, 2020 - Special Section: Event Analysis and Risk Management. October 14, 2020 Alemi F ed. Qual Manag Health Care. 2020;29(4):232-278. https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management Adverse event analysis is core for organizational learning from poor performance. This special section d…