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1621. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42949/psn-pdf
      February 19, 2014 - Impact of a clinical pharmacy admission medication reconciliation program on medication errors in "high-risk" patients. February 19, 2014 Buckley MS, Harinstein LM, Clark KB, et al. Impact of a clinical pharmacy admission medication reconciliation program on medication errors in "high-risk" patients. Ann Pharmacot…

1622. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35069/psn-pdf
      June 22, 2009 - Towards an organization with a memory: exploring the organizational generation of adverse events in health care. June 22, 2009 Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…

1623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44479/psn-pdf
      September 09, 2015 - Health literacy in primary care practice. September 9, 2015 Hersh L, Salzman B, Snyderman D. Health Literacy in Primary Care Practice. Am Fam Physician. 2015;92(2):118-124. https://psnet.ahrq.gov/issue/health-literacy-primary-care-practice Limited health literacy can lead to patients misunderstanding care instruct…

1624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45366/psn-pdf
      December 20, 2017 - A patient-centered prescription drug label to promote appropriate medication use and adherence. December 20, 2017 Wolf MS, Davis TC, Curtis LM, et al. A Patient-Centered Prescription Drug Label to Promote Appropriate Medication Use and Adherence. J Gen Intern Med. 2016;31(12):1482-1489. https://psnet.ahrq.gov/issu…

1625. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45263/psn-pdf
      September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…

1626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46697/psn-pdf
      January 10, 2018 - Primary care providers' perspectives on errors of omission. January 10, 2018 Poghosyan L, Norful AA, Fleck E, et al. Primary Care Providers' Perspectives on Errors of Omission. J Am Board Fam Med. 2017;30(6):733-742. doi:10.3122/jabfm.2017.06.170161. https://psnet.ahrq.gov/issue/primary-care-providers-perspectives…

1627. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838025/psn-pdf
      September 07, 2022 - Opportunities to mine EHRs for malpractice risk management and patient safety. September 7, 2022 Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/25160435221097422. https://psnet.ahrq.gov…

1628. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837000/psn-pdf
      May 06, 2022 - Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. May 6, 2022 Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022. https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath- …

1629. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837212/psn-pdf
      June 08, 2022 - Engaging Physicians in Teamwork Training for Quality and Safety - Or Why Don’t Your Physicians Get Engaged? May 25, 2022 AHA Team Training. June 8, 2022. https://psnet.ahrq.gov/issue/engaging-physicians-teamwork-training-quality-and-safety-or-why-dont-your- physicians-get Physicians are instrumental to the succes…

1630. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40690/psn-pdf
      August 17, 2011 - Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. August 17, 2011 Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):132-41. doi:10.1016/j.aorn.2010.09.…

1631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47319/psn-pdf
      October 10, 2018 - Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors. October 10, 2018 US Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/differences-strength-expression-product-labels-compounders-and- conventional-manufacturers-may Confusin…

1632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73541/psn-pdf
      July 28, 2021 - Misdiagnosis of heart failure: a systematic review of the literature. July 28, 2021 Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of heart failure: a systematic review of the literature. J Cardiac Failure. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. https://psnet.ahrq.gov/issue/misdiagnosis-heart-fail…

1633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73672/psn-pdf
      September 01, 2021 - ‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system? September 1, 2021 Outcalt C. The Atlantic. August 2021. https://psnet.ahrq.gov/issue/he-thought-what-he-was-doing-was-good-people-why-it-so-difficult-prevent- unnece…

1634. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39348/psn-pdf
      March 10, 2010 - How will it work? A qualitative study of strategic stakeholders' accounts of a patient safety initiative. March 10, 2010 Dixon-Woods M, Tarrant C, Willars J, et al. How will it work? A qualitative study of strategic stakeholders' accounts of a patient safety initiative. Qual Saf Health Care. 2010;19(1):74-8. doi:1…

1635. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73911/psn-pdf
      October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic review of the literature. October 6, 2021 Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256. https://psnet.ahrq.gov…

1636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41249/psn-pdf
      December 21, 2014 - Physicians' needs in coping with emotional stressors: the case for peer support. December 21, 2014 Hu Y-Y, Fix ML, Hevelone ND, et al. Physicians' needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012;147(3):212-217. doi:10.1001/archsurg.2011.312. https://psnet.ahrq.gov/issue/physici…

1637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42806/psn-pdf
      January 19, 2014 - Case studies of patient safety research classics to build research capacity in low- and middle-income countries. January 19, 2014 Andermann A, Wu AW, Lashoher A, et al. Case studies of patient safety research classics to build research capacity in low- and middle-income countries. Jt Comm J Qual Patient Saf. 2013;3…

1638. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42382/psn-pdf
      July 16, 2014 - Huddling for high reliability and situation awareness. July 16, 2014 Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467. https://psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness Se…

1639. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836932/psn-pdf
      April 13, 2022 - Nurses: Guilty verdict for dosing mistake could cost lives. April 13, 2022 Loller T. Associated Press. March 30, 2022. https://psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patien…

1640. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45173/psn-pdf
      November 18, 2016 - Impact of hospital-acquired conditions on financial liabilities for Medicare patients. November 18, 2016 Coomer NM, Kandilov AMG. Impact of hospital-acquired conditions on financial liabilities for Medicare patients. Am J Infect Control. 2016;44(11):1326-1334. doi:10.1016/j.ajic.2016.03.025. https://psnet.ahrq.gov…