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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46729/psn-pdf
    January 17, 2018 - Diagnostic error in pediatric cancer. January 17, 2018 Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila). 2017;57*1((1):11-18. doi:10.1177/0009922816687325. https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer Missed or delayed cancer diagnoses can lead …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849139/psn-pdf
    May 17, 2023 - How the opioid backlash went wrong. May 17, 2023 Freedman DH.  Newsweek Magazine. May 12, 2023. https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This articl…
  3. www.ahrq.gov/evidencenow/tools/ground-rules.html
    November 01, 2018 - Developing Ground Rules for Primary Care Team Communication Resource: Ground Rules for Team Communication  (PDF, 268 KB, 7 pages) Agreeing about how and when to communicate with each other can ensure productive, respectful meetings, and high-functioning teams during patient care. This resource can be used to…
  4. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-14.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.14. Project Team Composition—Hip and Knee Replacement Costs Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview He…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840477/psn-pdf
    November 30, 2022 - Common and consequential fractures that should not be missed in children. November 30, 2022 Tougas C, Brimmo O. Common and consequential fractures that should not be missed in children. Pediatr Ann. 2022;51(9):e357-e363. doi:10.3928/19382359-20220706-05. https://psnet.ahrq.gov/issue/common-and-consequential-fractu…
  6. www.ahrq.gov/nursing-home/resources/post-traumatic-stress-symptoms.html
    September 01, 2021 - Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review Resource:   Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review Prevention of post-traumatic stress symptoms (PTSS) in healthcare workers (HCWs)…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47794/psn-pdf
    April 03, 2019 - Perchance to think. April 3, 2019 Ofri D. Perchance to Think. New Engl J Med. 2019;380(13):1197-1199. doi:10.1056/NEJMp1814019. https://psnet.ahrq.gov/issue/perchance-think Production pressure, fatigue, and distraction can diminish effective decision-making. This commentary offers insights from an ambulatory care …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47938/psn-pdf
    May 01, 2019 - Drug diversion and impaired health care workers. May 1, 2019 Quick Safety. April 15, 2019;(48):1-3. https://psnet.ahrq.gov/issue/drug-diversion-and-impaired-health-care-workers Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837710/psn-pdf
    July 20, 2022 - Independent Neurology Inquiry. July 20, 2022 Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631. https://psnet.ahrq.gov/issue/independent-neurology-inquiry Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46800/psn-pdf
    May 16, 2018 - Ireland investigates cervical cancer screening scandal. May 16, 2018 O'Loughlin E. New York Times. April 30, 2018. https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misr…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42857/psn-pdf
    January 15, 2014 - The landscape of inappropriate laboratory testing: a 15- year meta-analysis. January 15, 2014 Zhi M, Ding EL, Theisen-Toupal J, et al. The landscape of inappropriate laboratory testing: a 15-year meta- analysis. PLoS One. 2013;8(11):e78962. doi:10.1371/journal.pone.0078962. https://psnet.ahrq.gov/issue/landscape-i…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40747/psn-pdf
    September 07, 2011 - Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. September 7, 2011 Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. Clin Med (Lond). 2011;11(4):317-321. https://psnet.ahrq.g…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39486/psn-pdf
    May 05, 2010 - Understanding handling of drug safety alerts: a simulation study. May 5, 2010 van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008. https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…
  14. www.ahrq.gov/hai/clabsi-tools/about.html
    March 01, 2018 - About the Toolkit Development Background This toolkit was developed based on the experiences of more than 1,000 ICUs that participated in the On the CUSP: Stop BSI project. These ICUs reduced CLABSIs by 41 percent using the CUSP method and resources included in this toolkit. Project partners Health Rese…
  15. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
    December 01, 2017 - It also asks which staff members are invited, who leads the meeting, and how often it occurs.
  16. www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/state/how-to-guide/how-to-guide.pdf
    August 01, 2024 - equally shared • Highly developed communication systems 19 Lead Organization The organization that leads … included the two project principal investigators (PIs), representatives from member partners, and the leads … accomplish their key activities, it can be helpful to also hold regular meetings of the working group leads
  17. effectivehealthcare.ahrq.gov/sites/default/files/related_files/medical-test-reviews-choosing-outcomes.ppt
    June 01, 2012 - Society as a whole may experience some outcomes, as when a test of an individual leads to a public health … The authors might also have explicitly included an outcome that examines whether the screening leads … to receipt of antibiotic treatment, essentially whether screening leads to change in clinical management
  18. effectivehealthcare.ahrq.gov/sites/default/files/medical-test-reviews-choosing-outcomes.ppt
    June 01, 2012 - Society as a whole may experience some outcomes, as when a test of an individual leads to a public health … The authors might also have explicitly included an outcome that examines whether the screening leads … to receipt of antibiotic treatment, essentially whether screening leads to change in clinical management
  19. www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
    January 01, 2025 - • Corrected by improving the receiving skills of practitioners • Creation of shared understanding leads …  Lack of standard process leads to delays in transfer or transfer to the wrong level of care. 12
  20. psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
    February 26, 2025 - RW : I guess that leads to a concern: if you think about what health systems have done to address other