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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42357/psn-pdf
    December 04, 2016 - Disclosing medical mistakes: a communication management plan for physicians. December 4, 2016 Petronio S, Torke A, Bosslet G, et al. Disclosing medical mistakes: a communication management plan for physicians. Perm J. 2013;17(2):73-9. doi:10.7812/TPP/12-106. https://psnet.ahrq.gov/issue/disclosing-medical-mistakes…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44583/psn-pdf
    February 17, 2016 - Root Cause Analysis Playbook. February 17, 2016 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/root-cause-analysis-playbook Risk management has recently focused on organization-wide improvement in patient safety. This publication discusses root cause analysis metho…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39180/psn-pdf
    December 16, 2009 - Description of inpatient medication management using cognitive work analysis. December 16, 2009 Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181bcad2f. https://psnet.ahrq.gov/is…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41114/psn-pdf
    February 01, 2012 - Rapid response systems: identification and management of the "prearrest state." February 1, 2012 McCurdy MT, Wood SL. Rapid response systems: identification and management of the "prearrest state". Emerg Med Clin North Am. 2012;30(1):141-52. doi:10.1016/j.emc.2011.09.012. https://psnet.ahrq.gov/issue/rapid-respons…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41992/psn-pdf
    May 23, 2013 - Errors as allies: error management training in health professions education. May 23, 2013 King A, Holder MG, Ahmed RA. Errors as allies: error management training in health professions education. BMJ Qual Saf. 2013;22(6):516-9. doi:10.1136/bmjqs-2012-000945. https://psnet.ahrq.gov/issue/errors-allies-error-managem…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35049/psn-pdf
    June 22, 2009 - Theoretical approaches for investigating patient safety.   June 22, 2009 Thomas MB, Houston S. Theoretical approaches for investigating patient safety. Clin Nurse Spec. 2005;19(3):129-134. https://psnet.ahrq.gov/issue/theoretical-approaches-investigating-patient-safety The authors offer a brief introduction to thr…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61031/psn-pdf
    October 14, 2020 - Special Section: Event Analysis and Risk Management. October 14, 2020 Alemi F ed. Qual Manag Health Care. 2020;29(4):232-278. https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management Adverse event analysis is core for organizational learning from poor performance. This special section d…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47049/psn-pdf
    July 10, 2019 - Injectable Opioid Shortages: Suggestions for Management and Conservation. July 10, 2019 University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists. https://psnet.ahrq.gov/issue/injectable-opioid-shortages-suggestions-management-and-conservation Efforts to limit the availabilit…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72484/psn-pdf
    November 18, 2020 - Management of Operating Room Critical Events. November 18, 2020 Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922. https://psnet.ahrq.gov/issue/management-operating-room-critical-events Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on mana…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35301/psn-pdf
    December 01, 2022 - Guiding Principles to Achieve Continuity in Medication Management. December 1, 2022 Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1- 76007-471-5. https://psnet.ahrq.gov/issue/guiding-principles-achieve-continuity-medication-management Originally published in 2005, the…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42290/psn-pdf
    May 22, 2013 - Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool. May 22, 2013 Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.  https://psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management- learning-tool Articles in this special issue outline the developm…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34679/psn-pdf
    February 09, 2011 - Patient complaints and malpractice risk. February 9, 2011 Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951-7. https://psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk This study examines the association between physicians’ patient complaint …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42951/psn-pdf
    September 16, 2014 - Novel approach to cardiac alarm management on telemetry units. September 16, 2014 Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13-22. doi:10.1097/JCN.0000000000000114. https://psnet.ahrq.gov/issue/novel-approach-cardiac-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36260/psn-pdf
    May 27, 2011 - The effect of physicians' long-term use of CPOE on their test management work practices. May 27, 2011 Callen JL, Westbrook JI, Braithwaite J. The effect of physicians' long-term use of CPOE on their test management work practices. J Am Med Inform Assoc. 2006;13(6):643-52. https://psnet.ahrq.gov/issue/effect-physic…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47812/psn-pdf
    April 17, 2019 - Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England. April 17, 2019 Lawton R, Robinson O, Harrison R, et al. Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette s…
  17. psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
    November 19, 2015 - Audiovisual When Things Go Wrong: Voices of Patients and Families. Citation Text: When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation Copy Citation Save Save to your library Print Download PDF Shar…
  18. psnet.ahrq.gov/issue/nursing-crew-resource-management-follow-report-veterans-health-administration
    September 27, 2016 - Commentary Nursing crew resource management: a follow-up report from the Veterans Health Administration. Citation Text: Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1…
  19. psnet.ahrq.gov/issue/nursing-home-administrators-opinions-resident-safety-culture-nursing-homes
    April 06, 2011 - Study Nursing home administrators' opinions of the resident safety culture in nursing homes. Citation Text: Castle NG, Handler S, Engberg J, et al. Nursing home administrators' opinions of the resident safety culture in nursing homes. Health Care Manage Rev. 2007;32(1):66-76. Copy Ci…
  20. psnet.ahrq.gov/issue/literature-review-individual-and-systems-factors-contribute-medication-errors-nursing
    April 22, 2011 - Review A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Citation Text: Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice…

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