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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837025/psn-pdfMay 04, 2022 - Central venous catheter guidewire retention: lessons from England's never event database. May 4, 2022 Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10.1097/pts.0000000000000826. https:/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836823/psn-pdfMarch 30, 2022 - Five-year audit of adherence to an anaesthesia pre- induction checklist. March 30, 2022 Fuchs A, Frick S, Huber M, et al. Five?year audit of adherence to an anaesthesia pre?induction checklist. Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704. https://psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthes… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46370/psn-pdfNovember 08, 2017 - Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. November 8, 2017 Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. B… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60175/psn-pdfApril 01, 2020 - ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. April 1, 2020 American College of Radiology. March 11, 2020. https://psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct- suspected-covid-19 As COVID-19 s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46014/psn-pdfApril 05, 2017 - Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. April 5, 2017 Prakash S, Bihari S, Need P, et al. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC Med Educ. 2017;17(1):36. doi:10.1186/s12909-017-0871-x… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44688/psn-pdfFebruary 23, 2018 - Improving diagnosis in health care—the next imperative for patient safety. February 23, 2018 Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp1512241. https://psnet.ahrq.gov/issue/improving-diagnosis-health-care… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866202/psn-pdfJuly 24, 2024 - Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety. June 26, 2024 Agency for Healthcare Research and Quality. July 24, 2024. https://psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers- and-improve Medication errors a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73709/psn-pdfSeptember 15, 2021 - Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; a structured approach to developing resilience or natural organisational responses. September 15, 2021 Pring ET, Malietzis G, Kendall SWH, et al. Crisis management for surgical teams and their leaders, lessons from the COV… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47376/psn-pdfNovember 02, 2018 - Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. November 2, 2018 Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836915/psn-pdfApril 13, 2022 - Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review. April 13, 2022 Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical Electronic Health Record workaround… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848366/psn-pdfMay 03, 2023 - The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. May 3, 2023 Ward CE, Taylor M, Keeney C, et al. The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. Prehosp Emerg Care. 2… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837698/psn-pdfJuly 20, 2022 - White patients’ physical responses to healthcare treatments are influenced by provider race and gender. July 20, 2022 Howe LC, Hardebeck EJ, Eberhardt JL, et al. White patients’ physical responses to healthcare treatments are influenced by provider race and gender. Proc Natl Acad Sci USA. 2022;119(27):e2007717119. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836966/psn-pdfApril 20, 2022 - Performance variability in perioperative sentinel events: report on a nationwide data set. April 20, 2022 Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.1093/bjs/znac067. https://psnet.ahrq… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72664/psn-pdfJanuary 20, 2021 - Delayed flow is a risk to patient safety: a mixed method analysis of emergency department patient flow. January 20, 2021 Pryce A, Unwin M, Kinsman L, et al. Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow. Int Emerg Nurs. 2020;54:100956. doi:10.1016/j.ienj.2020… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60050/psn-pdfMarch 18, 2020 - Zero harm in health care. March 18, 2020 Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2). doi:10.1056/cat.19.1137. https://psnet.ahrq.gov/issue/zero-harm-health-care Health systems are encouraged to strive for zero preventable harm, but achieving this goal require… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45445/psn-pdfSeptember 27, 2016 - Using Kotter's change model for implementing bedside handoff: a quality improvement project. September 27, 2016 Small A, Gist D, Souza D, et al. Using Kotter's Change Model for Implementing Bedside Handoff: A Quality Improvement Project. J Nurs Care Qual. 2016;31(4):304-9. doi:10.1097/NCQ.0000000000000212. https:/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45813/psn-pdfJanuary 18, 2017 - Considering chance in quality and safety performance measures: an analysis of performance reports by boards in English NHS trusts. January 18, 2017 Anhøj J, Hellesøe A-MB. The problem with red, amber, green: the need to avoid distraction by random variation in organisational performance measures. BMJ Qual Saf. 201… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45706/psn-pdfSeptember 01, 2018 - Improving communication and resolution following adverse events using a patient-created simulation exercise. September 1, 2018 Gallagher TH, Etchegaray J, Bergstedt B, et al. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. Health Serv Res. 2016;51 Suppl … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50889/psn-pdfFebruary 12, 2020 - Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology. February 12, 2020 Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A Novel Resource for Targeting Amb… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73443/psn-pdfJune 30, 2021 - Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period. June 30, 2021 Le Cornu E, Murray S, Brown EJ, et al. Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen?year period. J Med Radiat Sci. 2021;6…
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