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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44408/psn-pdf
    April 12, 2017 - Enhancing Surgical Performance: A Primer in Non- technical Skills. April 12, 2017 Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322. https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills Non-technical skill development is gaining attention as a way …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60999/psn-pdf
    October 07, 2020 - Global Report on the Epidemiology and Burden of Sepsis: Current Evidence, Identifying Gaps and Future Directions. October 7, 2020 Geneva, Switzerland; World Health Organization: September 2020. ISBN 9789240010789. https://psnet.ahrq.gov/issue/global-report-epidemiology-and-burden-sepsis-current-evidence-identifying…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862610/psn-pdf
    February 14, 2024 - Assessing the safety of a new clinical decision support system for a national helpline. February 14, 2024 Luckraj N, Strazzari R, Coiera E, et al. Assessing the safety of a new clinical decision support system for a national helpline. Stud Health Technol Inform. 2024;310:514-518. doi:10.3233/shti231018. https://ps…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44410/psn-pdf
    August 12, 2015 - Workarounds in the workplace: a second look. August 12, 2015 Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242. doi:10.1097/NOR.0000000000000161. https://psnet.ahrq.gov/issue/workarounds-workplace-second-look Workarounds are prevalent in health care and create opport…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849138/psn-pdf
    May 17, 2023 - Non-accidental Injuries in Infants Attending the Emergency Department. May 17, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; April 2023. https://psnet.ahrq.gov/issue/non-accidental-injuries-infants-attending-emergency-department Misattribution of child maltreatment injuries can be a serious misdiag…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38345/psn-pdf
    February 17, 2009 - Association of communication between hospital-based physicians and primary care providers with patient outcomes. February 17, 2009 Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3)…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47462/psn-pdf
    October 31, 2018 - Emergency department checklist: an innovation to improve safety in emergency care. October 31, 2018 Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-000325. https://psnet.ahrq.gov/issue/e…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837667/psn-pdf
    July 13, 2022 - Challenges and opportunities of patient safety event reporting. July 13, 2022 Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform. 2022;291:133-150. doi:10.3233/shti220014. https://psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting Repor…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73602/psn-pdf
    August 18, 2021 - The Child Health PSO at 10 years: an emerging learning network. August 18, 2021 Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network. Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449. https://psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-le…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41006/psn-pdf
    December 21, 2011 - Failure to notify reportable test results: significance in medical malpractice. December 21, 2011 Gale BD, Bissett-Siegel DP, Davidson SJ, et al. Failure to notify reportable test results: significance in medical malpractice. J Am Coll Radiol. 2011;8(11):776-9. doi:10.1016/j.jacr.2011.06.023. https://psnet.ahrq.go…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44838/psn-pdf
    February 10, 2016 - ADVERSE drug events: incidence and risk reduction across the care continuum. February 10, 2016 Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum. Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03. https://psnet.ahrq.gov/issue/adverse-drug-eve…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40209/psn-pdf
    April 22, 2011 - The efficacy of computer-enabled discharge communication interventions: a systematic review. April 22, 2011 Motamedi SM, Posadas-Calleja J, Straus SE, et al. The efficacy of computer-enabled discharge communication interventions: a systematic review. BMJ Qual Saf. 2011;20(5):403-15. doi:10.1136/bmjqs.2009.034587. …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45619/psn-pdf
    August 16, 2017 - Checking the lists: a systematic review of electronic checklist use in health care. August 16, 2017 Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006. https://psnet.ahrq.gov/issue/checking-lists-s…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867190/psn-pdf
    November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right. November 20, 2024 Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024; https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right Patients are partners in health care and can inform actions to id…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46628/psn-pdf
    December 18, 2017 - Residency evaluations—where is the patient voice? December 18, 2017 Tummalapalli SL. Residency Evaluations-Where Is the Patient Voice? JAMA Intern Med. 2017;177(12):1722-1723. doi:10.1001/jamainternmed.2017.6029. https://psnet.ahrq.gov/issue/residency-evaluations-where-patient-voice Residents rarely receive feedba…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74133/psn-pdf
    January 01, 2022 - Predicting avoidable hospital events in Maryland. December 1, 2021 Henderson M, Han F, Perman C, et al. Predicting avoidable hospital events in Maryland. Health Serv Res. 2022;57(1):192-199. doi:10.1111/1475-6773.13891. https://psnet.ahrq.gov/issue/predicting-avoidable-hospital-events-maryland With the goal of imp…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44048/psn-pdf
    November 20, 2015 - Clinical handover of the critically ill postoperative patient: an integrative review. November 20, 2015 Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001. https://psnet.ahrq…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36992/psn-pdf
    September 14, 2011 - Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. September 14, 2011 Grant MJC, Larsen G. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. J Nurs Care Qual. 2007;22…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35679/psn-pdf
    June 28, 2010 - Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. June 28, 2010 Frush K, Hohenhaus S, Luo X, et al. Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. Pediatr Emerg C…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46330/psn-pdf
    September 24, 2017 - Systemic error in radiology. September 24, 2017 Waite S, Scott JM, Legasto A, et al. Systemic Error in Radiology. AJR Am J Roentgenol. 2017;209(3):629- 639. doi:10.2214/AJR.16.17719. https://psnet.ahrq.gov/issue/systemic-error-radiology Radiology interpretation errors can contribute to diagnostic error. This comme…

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