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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47802/psn-pdf
    March 04, 2019 - The path to diagnostic excellence includes feedback to calibrate how clinicians think. March 4, 2019 Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113. https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47808/psn-pdf
    May 15, 2019 - Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation. May 15, 2019 Woodham LA, Round J, Stenfors T, et al. Virtual patients designed for training against medical error: Exploring the impact of decision-making on learner motivation. PLoS One. 20…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34662/psn-pdf
    December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report. December 24, 2008 Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90. https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report Fifteen months after releasing its report on patient safety (To Err Is …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74102/psn-pdf
    January 01, 2022 - Workforce planning and safe workload in sterile compounding hospital pharmacy services. November 24, 2021 Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379. https://psnet…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35159/psn-pdf
    January 02, 2017 - Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. January 2, 2017 Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Patient Saf. 2005;31(7):406-13. https://psnet.ahrq.gov…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47068/psn-pdf
    June 25, 2018 - The need for closed-loop systems for management of abnormal test results. June 25, 2018 Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425. https://psnet.ahrq.gov/issue/need-closed-loop-systems…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838193/psn-pdf
    September 28, 2022 - Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. September 28, 2022 de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147. …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47586/psn-pdf
    March 20, 2019 - Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. March 20, 2019 Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Admin…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73125/psn-pdf
    April 07, 2021 - Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions. April 7, 2021 Gangopadhyaya A. Washington DC: Urban Institute; March 29, 2021. https://psnet.ahrq.gov/issue/black-patients-are-more-likely-white-patients-be-hospitals-worse-patient- safety-conditions Racial…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39600/psn-pdf
    June 16, 2010 - Developing a patient safety surveillance system to identify adverse events in the intensive care unit. June 16, 2010 Stockwell DC, Kane-Gill SL. Developing a patient safety surveillance system to identify adverse events in the intensive care unit. Crit Care Med. 2010;38(6 Suppl):S117-25. doi:10.1097/CCM.0b013e3181d…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74003/psn-pdf
    October 27, 2021 - Test-retest reliability of an experienced Global Trigger Tool review team. October 27, 2021 Bjørn B, Anhøj J, Østergaard M, et al. Test-retest reliability of an experienced Global Trigger Tool review team. J Patient Saf. 2021;17(7):e593-e598. doi:10.1097/pts.0000000000000433. https://psnet.ahrq.gov/issue/test-rete…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35909/psn-pdf
    October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing Harm to Patients. October 7, 2008 McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006. https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients This report presents ten case studies to illustrate interventions that address p…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35365/psn-pdf
    February 17, 2011 - Accidental deaths, saved lives, and improved quality. February 17, 2011 Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34667/psn-pdf
    January 17, 2018 - Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. January 17, 2018 Smetzer JL, Cohen MR. Hosp Pharm. 1998;33(6):640-642,645-646,654-657. https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond- blaming-individuals In Octobe…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45766/psn-pdf
    February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use. February 8, 2017 Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016. https://psnet.ahrq.gov/issue/prescription-drug-monit…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43580/psn-pdf
    October 01, 2014 - Reducing medication errors in critical care: a multimodal approach. October 1, 2014 Kruer RM, Jarrell AS, Latif A. Reducing medication errors in critical care: a multimodal approach. Clin Pharmacol. 2014;6:117-26. doi:10.2147/CPAA.S48530. https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multim…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45630/psn-pdf
    March 29, 2017 - Do leadership style, unit climate, and safety climate contribute to safe medication practices? March 29, 2017 Farag A, Tullai-McGuinness S, Anthony MK, et al. Do Leadership Style, Unit Climate, and Safety Climate Contribute to Safe Medication Practices? J Nurs Adm. 2017;47(1):8-15. https://psnet.ahrq.gov/issue/do-…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836753/psn-pdf
    March 16, 2022 - Inequities in quality and safety outcomes for hospitalized children with intellectual disability. March 16, 2022 Mimmo L, Harrison R, Travaglia J, et al. Inequities in quality and safety outcomes for hospitalized children with intellectual disability. Dev Med Child Neurol. 2022;64(3):314-322. doi:10.1111/dmcn.15066…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50378/psn-pdf
    September 25, 2019 - Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center. September 25, 2019 Lewis-Pierre LT, Anglade D, Saber D, et al. Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center. J Nurs Manag. 2019;27(5):1005-1010.…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47279/psn-pdf
    July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the Home. July 23, 2018 Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence ass…

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