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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40346/psn-pdf
    November 26, 2014 - Inability of providers to predict unplanned readmissions. November 26, 2014 Allaudeen N, Schnipper JL, Orav J, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011;26(7):771-6. doi:10.1007/s11606-011-1663-3. https://psnet.ahrq.gov/issue/inability-providers-predict-unplanned-readmi…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36065/psn-pdf
    May 27, 2011 - Passing the "Yo' Mama" test. May 27, 2011 Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18. https://psnet.ahrq.gov/issue/passing-yo-mama-test This article discusses how a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35441/psn-pdf
    September 18, 2009 - Bridging the communication gap in the operating room with medical team training. September 18, 2009 Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-4. https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-r…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36056/psn-pdf
    September 27, 2010 - Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. September 27, 2010 McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8. https://psnet.ahrq.gov/issue/path-safety-benefits-2005-patie…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36448/psn-pdf
    November 22, 2006 - Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups. November 22, 2006 Kernaghan D; Penney GC. https://psnet.ahrq.gov/issue/do-panels-vary-when-assessing-intrapartum-adverse-events-reproducibility- assessments-hospital The authors analyz…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867646/psn-pdf
    January 01, 2022 - Opioid Safety Initiative Toolkit. January 1, 2022 VA Pain Management, Opioid Safety, and PDMP (PMOP). U.S Department of Veterans Affairs; 2022. Opioid Safety Initiative Toolkit. https://psnet.ahrq.gov/issue/opioid-safety-initiative-toolkit Increasing safe opioid prescribing is a patient safety priority. The VA’s O…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40351/psn-pdf
    April 06, 2011 - Acute care patients discuss the patient role in patient safety. April 6, 2011 Rathert C, Huddleston N, Pak Y. Acute care patients discuss the patient role in patient safety. Health Care Manage Rev. 2011;36(2):134-144. doi:10.1097/HMR.0b013e318208cd31. https://psnet.ahrq.gov/issue/acute-care-patients-discuss-patien…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41850/psn-pdf
    November 21, 2012 - TeamSTEPPS: the patient safety tool that needs to be implemented. November 21, 2012 Clapper TC, Kong M. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented. Clin Simul Nurs. 2011;8(8). doi:10.1016/j.ecns.2011.03.002. https://psnet.ahrq.gov/issue/teamstepps-patient-safety-tool-needs-be-implemented De…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45735/psn-pdf
    July 17, 2017 - CMPA Good Practices Guide. July 17, 2017 Ottawa, Ontario: Canadian Medical Protective Association; 2016. https://psnet.ahrq.gov/issue/cmpa-good-practices-guide Key patient safety topics include human factors, teamwork, adverse events, communication, professionalism, and risk management. This website provides resou…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36679/psn-pdf
    December 21, 2009 - Manic for medication safety: bar codes and drug information databases are helping to reduce medication errors. December 21, 2009 Rogoski RR. Manic for medication safety. Health management technology. 2007;28(2):14, 16-8. https://psnet.ahrq.gov/issue/manic-medication-safety-bar-codes-and-drug-information-databases-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42601/psn-pdf
    September 18, 2013 - 'You talking to me?' Docs and feedback. September 18, 2013 Diamond F. 'You talking to me?' Docs and feedback. Managed care (Langhorne, Pa.). 2013;22(7):30-2. https://psnet.ahrq.gov/issue/you-talking-me-docs-and-feedback Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaki…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42021/psn-pdf
    February 13, 2013 - Nurses discuss bedside handover and using written handover sheets. February 13, 2013 Johnson M, Cowin LS. Nurses discuss bedside handover and using written handover sheets. J Nurs Manag. 2013;21(1):121-9. doi:10.1111/j.1365-2834.2012.01438.x. https://psnet.ahrq.gov/issue/nurses-discuss-bedside-handover-and-using-w…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43510/psn-pdf
    April 21, 2015 - Running a hospital patient safety campaign: a qualitative study. April 21, 2015 Ozieranski P, Robins V, Minion J, et al. Running a hospital patient safety campaign: a qualitative study. J Health Organ Manag. 2014;28(4):562-75. https://psnet.ahrq.gov/issue/running-hospital-patient-safety-campaign-qualitative-study …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34576/psn-pdf
    May 27, 2015 - An Agenda for Research in Ambulatory Patient Safety. May 27, 2015 Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA https://psnet.ahrq.gov/issue/agenda-research-ambulatory-patient-safety This summarizes a multidisciplinary conference (November 30 and December 1, 2000)…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35933/psn-pdf
    July 26, 2010 - Surgical 'never events': how common are adverse occurrences? July 26, 2010 West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105. https://psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences The…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37125/psn-pdf
    October 04, 2011 - Current pulse: can a production system reduce medical errors in health care? October 4, 2011 Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238. https://psnet.ahrq.gov/issue/current-pulse-can-production-system-reduc…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46998/psn-pdf
    August 01, 2019 - 10 Facts on Patient Safety. June 27, 2018 Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health Organization: August 2019. https://psnet.ahrq.gov/issue/10-facts-patient-safety This publication highlights statistics that illustrate the global impact of patient harm. The i…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39335/psn-pdf
    September 24, 2016 - Interruptions and multitasking in nursing care. September 24, 2016 Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf. 2010;36(3):126-132. https://psnet.ahrq.gov/issue/interruptions-and-multitasking-nursing-care This study observed nurses for 4-hour periods and foun…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35769/psn-pdf
    January 02, 2017 - A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). January 2, 2017 Pronovost P, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29. https://psnet.ahrq.gov/issue/web-based-tool-comprehensive-unit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39113/psn-pdf
    November 18, 2009 - From a blame culture to a just culture in health care. November 18, 2009 Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manag Rev. 2009;34(4):312-322. doi:10.1097/HMR.0b013e3181a3b709. https://psnet.ahrq.gov/issue/blame-culture-just-culture-health-care This article…

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