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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60707/psn-pdf
    July 22, 2020 - The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. July 22, 2020 Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to an…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47853/psn-pdf
    April 10, 2019 - Does a unit shift report "blackout" period improve patient safety? April 10, 2019 Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8- 10. doi:10.1097/01.NUMA.0000553500.85897.51. https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849610/psn-pdf
    May 31, 2023 - Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. May 31, 2023 Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. J Healthc Qual. 2023;45(3):140-147. doi:10.1097/jhq.0000000000000374.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45106/psn-pdf
    August 16, 2017 - The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff. August 16, 2017 MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47193/psn-pdf
    September 05, 2018 - Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review. September 5, 2018 Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care; a narrative review. Saf Health. 2018;4(7). doi:10…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36280/psn-pdf
    May 27, 2011 - Types of unintended consequences related to computerized provider order entry. May 27, 2011 Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-56. https://psnet.ahrq.gov/issue/types-unintended-consequences-rela…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47273/psn-pdf
    September 05, 2018 - Natural language processing and its implications for the future of medication safety: a narrative review of recent advances and challenges. September 5, 2018 Wong A, Plasek JM, Montecalvo SP, et al. Natural Language Processing and Its Implications for the Future of Medication Safety: A Narrative Review of Recent A…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47395/psn-pdf
    October 10, 2018 - Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. October 10, 2018 Scott IA, Pillans PI, Barras M, et al. Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications:…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47515/psn-pdf
    February 25, 2019 - Blood sampling guidelines with focus on patient safety and identification—a review. February 25, 2019 Cornes M, Ibarz M, Ivanov H, et al. Blood sampling guidelines with focus on patient safety and identification - a review. Diagnosis (Berl). 2019;6(1):33-37. doi:10.1515/dx-2018-0042. https://psnet.ahrq.gov/issue/b…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60792/psn-pdf
    August 12, 2020 - Nurse workarounds in the electronic health record: an integrative review. August 12, 2020 Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050. https://psnet.ahrq.gov/issue/nurse-workaroun…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858170/psn-pdf
    December 13, 2023 - Unsafe care in residential settings for older adults. A content analysis of accreditation reports. December 13, 2023 Hibbert PD, Ash R, Molloy CJ, et al. Unsafe care in residential settings for older adults: a content analysis of accreditation reports. Int J Qual Health Care. 2023;35(4):mzad085. doi:10.1093/intqhc/…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61120/psn-pdf
    November 11, 2020 - Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020 Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. doi:10.1055/s-0040-1716537. http…
  13. psnet.ahrq.gov/issue/sorry-works
    November 15, 2024 - Multi-use Website Sorry Works! Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 17, 2011 Sorry Works! supports a full-disclosure approach to medical errors. They encourage…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866733/psn-pdf
    September 18, 2024 - A coproduced family reporting intervention to improve safety surveillance and reduce disparities. September 18, 2024 Khan A, Baird JD, Mauskar S, et al. A coproduced family reporting intervention to improve safety surveillance and reduce disparities. Pediatrics. 2024;154(4):e2023065245. doi:10.1542/peds.2023-065245…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44805/psn-pdf
    January 27, 2016 - NHS Safety Thermometer Reports. January 27, 2016 Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017. https://psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november- 2014-november-2015 The NHS Safety Thermometer was a tool developed by …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857581/psn-pdf
    January 01, 2025 - Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long- Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes. Au…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72575/psn-pdf
    January 01, 2021 - Missing the near miss: recognizing valuable learning opportunities in radiation oncology. December 16, 2020 Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.1016/j.prro.2020.09.007. https://…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36604/psn-pdf
    June 04, 2024 - Adverse Health Events in Minnesota: Annual Reports. June 4, 2024 St Paul, MN: Minnesota Department of Health. https://psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35551/psn-pdf
    June 08, 2010 - Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. June 8, 2010 Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthesiology. 2005;103(6):1121-1129. https…
  20. psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
    January 01, 2016 - In Conversation With… Mark L. Graber, MD January 1, 2016  Also Read an Essay Citation Text: In Conversation With… Mark L. Graber, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. …

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