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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851348/psn-pdf
    July 12, 2023 - Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. July 12, 2023 Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life- Sustaining Treatments thr…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41572/psn-pdf
    October 29, 2012 - Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. October 29, 2012 Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmjqs-2012-000803. https://psnet.ahrq…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41250/psn-pdf
    December 21, 2014 - Disclosure of "nonharmful" medical errors and other events: duty to disclose. December 21, 2014 Chamberlain CJ, Koniaris LG, Wu AW, et al. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012;147(3):282-6. doi:10.1001/archsurg.2011.1005. https://psnet.ahrq.gov/issue/disclos…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42178/psn-pdf
    April 10, 2013 - Outside case review of surgical pathology for referred patients: the impact on patient care. April 10, 2013 Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients: the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA. htt…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862991/psn-pdf
    February 21, 2024 - Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incident data. February 21, 2024 Jones MD, Liu S, Powell F, et al. Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incide…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37386/psn-pdf
    January 06, 2017 - Medication reconciliation in ambulatory oncology. January 6, 2017 Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual Patient Saf. 2007;33(12):750-7. https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology The Joint Commission mandates systems…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43567/psn-pdf
    October 21, 2016 - National Action Plan for Adverse Drug Event Prevention. October 21, 2016 Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014. https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention This national action pla…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60539/psn-pdf
    July 10, 2017 - Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. July 10, 2017 Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. Jt Comm J Qual Patient Saf. 2017;43(9):433-447. doi:1…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60185/psn-pdf
    April 01, 2020 - Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. April 1, 2020 Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suici…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39581/psn-pdf
    January 03, 2017 - An implementation strategy for a multicenter pediatric rapid response system in Ontario. January 3, 2017 Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47561/psn-pdf
    February 22, 2019 - "Change is what can actually make the tough times better": a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. February 22, 2019 Louch G, Mohammed MA, Hughes L, et al. "Change is what can actually make the tough times better": A patient-centred patient safety interven…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73364/psn-pdf
    January 01, 2022 - Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. June 9, 2021 Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59. doi:10.1177/10…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836719/psn-pdf
    March 09, 2022 - Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey. March 9, 2022 Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Prevalence and factors associated with patient-requested corrections to the medical record throug…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37776/psn-pdf
    January 31, 2011 - Barcoded medication administration: a last line of defense. January 31, 2011 Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA. 2008;299(18):2200-2. doi:10.1001/jama.299.18.2200. https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense Barcoding techn…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60591/psn-pdf
    June 17, 2020 - National trends in the safety performance of electronic health record systems from 2009 to 2018. June 17, 2020 Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547. htt…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866908/psn-pdf
    October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. October 9, 2024 Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.33940/001c.117084. https://psnet…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45710/psn-pdf
    December 22, 2017 - Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? December 22, 2017 Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017;26(5):381-387. doi:10.1136/…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837737/psn-pdf
    July 27, 2022 - Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data. July 27, 2022 Lear R, Freise L, Kybert M, et al. Patients' willingness and ability to identify and respond to errors in their personal health records: mixed m…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46459/psn-pdf
    August 20, 2018 - Readiness of US general surgery residents for independent practice. August 20, 2018 George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.0000000000002414. https://psnet.ahrq.gov/issue/readiness-us-general-surger…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42232/psn-pdf
    May 08, 2013 - The Measurement and Monitoring of Safety. May 8, 2013 Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447. https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety Despite great effort, health care organizations are still learning how to identify safety problems, es…

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