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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44649/psn-pdf
    November 11, 2015 - Seven (potentially) deadly prescribing errors. November 11, 2015 Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015. https://psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors Errors in the prescribing process can lead to adverse drug events. This slide set provides information about commo…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45039/psn-pdf
    September 27, 2016 - Deaths following prehospital safety incidents: an analysis of a national database. September 27, 2016 Yardley I, Donaldson LJ. Deaths following prehospital safety incidents: an analysis of a national database. Emerg Med J. 2016;33(10):716-721. doi:10.1136/emermed-2015-204724. https://psnet.ahrq.gov/issue/deaths-fo…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39559/psn-pdf
    December 17, 2010 - Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. December 17, 2010 James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(5):735-47. doi:10.1007/s10459-01…

  4. Implementing a Daily Team Huddle—AMA CME Module | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/team-huddle.html
    February 01, 2025 - Implementing a Daily Team Huddle—AMA CME Module Resource: Daily Team Huddles Boost Productivity and Teamwork This toolkit helps to identify strategies to incorporate daily huddles into practice workflows, to devise daily huddle structure, and to measure the success of the daily huddle for revisions. The resour…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74188/psn-pdf
    December 15, 2021 - Semantically ambiguous language in the teaching operating room. December 15, 2021 Liu C, McKenzie A, Sutkin G. Semantically ambiguous language in the teaching operating room. J Surg Edu. 2021;78(6):1938-1947. doi:10.1016/j.jsurg.2021.03.020. https://psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-ope…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34805/psn-pdf
    November 07, 2017 - Medication errors in neonatal and paediatric intensive- care units. November 7, 2017 Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2(8659):374-6. https://psnet.ahrq.gov/issue/medication-errors-neonatal-and-paediatric-intensive-care-units Th…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38551/psn-pdf
    April 15, 2009 - Harm caused by adverse events in primary care: a clinical observational study. April 15, 2009 Wetzels R, Wolters R, van Weel C, et al. Harm caused by adverse events in primary care: a clinical observational study. J Eval Clin Pract. 2009;15(2):323-7. doi:10.1111/j.1365-2753.2008.01005.x. https://psnet.ahrq.gov/iss…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43700/psn-pdf
    November 19, 2014 - Appropriate use of medical interpreters. November 19, 2014 Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-80. https://psnet.ahrq.gov/issue/appropriate-use-medical-interpreters Language barriers between patients and providers can contribute to misunderstandings and lead…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43118/psn-pdf
    April 16, 2014 - NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0. April 16, 2014 Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014. https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73586/psn-pdf
    January 01, 2022 - 'More than words' - interpersonal communication, cognitive bias and diagnostic errors. August 11, 2021 Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec.2021.05.012. https://psnet.ahrq.gov/…

  11. Exhibit 3.16. Project Team Composition–Cardiology Follow-up Appointment Scheduling | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-16.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.16. Project Team Composition–Cardiology Follow-up Appointment Scheduling Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46329/psn-pdf
    September 06, 2017 - Risk factors of missed colorectal lesions after colonoscopy. September 6, 2017 Lee J, Park SW, Kim YS, et al. Risk factors of missed colorectal lesions after colonoscopy. Medicine (Baltimore). 2017;96(27):e7468. doi:10.1097/MD.0000000000007468. https://psnet.ahrq.gov/issue/risk-factors-missed-colorectal-lesions-af…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40130/psn-pdf
    January 12, 2011 - Patient safety culture: factors that influence clinician involvement in patient safety behaviours. January 12, 2011 Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Qual Saf Health Care. 2010;19(6):585-91. doi:10.1136/qshc…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853971/psn-pdf
    September 27, 2023 - Unconscious bias among health professionals: a scoping review. September 27, 2023 Meidert U, Dönnges G, Bucher T, et al. Unconscious bias among health professionals: a scoping review. Int J Environ Res Public Health. 2023;20(16):6569. doi:10.3390/ijerph20166569. https://psnet.ahrq.gov/issue/unconscious-bias-among-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46701/psn-pdf
    December 20, 2017 - The other big drug problem: older people taking too many pills. December 20, 2017 Boodman SG. Washington Post. December 9, 2017. https://psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills The prevalence of polypharmacy among older patients represents an important concern for health care…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73885/psn-pdf
    September 29, 2021 - Reporting of unsafe conditions at an academic women and children's hospital. September 29, 2021 Grabinski ZG, Babineau J, Jamal N, et al. Reporting of unsafe conditions at an academic women and children's hospital. Jt Comm J Qual Patient Saf. 2021;47(11):731-738. doi:10.1016/j.jcjq.2021.08.004. https://psnet.ahrq.…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74100/psn-pdf
    November 24, 2021 - Pediatric medication errors and reduction strategies in the perioperative period. November 24, 2021 Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324. https://psnet.ahrq.gov/issue/pediatric-medication-errors-and-reduction-strategies-perioperative-period Pediatric medication errors during anesthesia …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35101/psn-pdf
    November 04, 2015 - Hospital finances and patient safety outcomes. November 4, 2015 Encinosa W, Bernard DM. Hospital finances and patient safety outcomes. Inquiry. 2005;42(1):60-72. https://psnet.ahrq.gov/issue/hospital-finances-and-patient-safety-outcomes This AHRQ–funded study examined the relationship between hospital profit margin…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47709/psn-pdf
    August 07, 2019 - Medication histories in critically ill patients completed by pharmacy personnel. August 7, 2019 Kram BL, Trammel MA, Kram SJ, et al. Medication histories in critically ill patients completed by pharmacy personnel. Ann Pharmacother. 2019;53(6):596-602. doi:10.1177/1060028018825483. https://psnet.ahrq.gov/issue/medi…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867650/psn-pdf
    January 01, 2022 - Opioid deprescribing toolkit. January 1, 2022 Health Innovation East, National Health Service. Opioid deprescribing toolkit. https://psnet.ahrq.gov/issue/opioid-deprescribing-toolkit Sudden discontinuation of long-term prescription opioid use can lead to adverse outcomes for patients. Based on research and clinici…
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