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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45834/psn-pdf
    February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. February 22, 2017 White AA, Brock DM, McCotter PI, et al. Implementing an error disclosure coaching model: A multicenter case study. J Healthc Risk Manag. 2017;36(3):34-45. doi:10.1002/jhrm.21260. https://psnet.ahrq.gov/issue/implementing-e…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42743/psn-pdf
    November 20, 2013 - Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice. November 20, 2013 Leigh J, Flynn J. Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice. J Healthc Risk Manag. 2013;33(2):27-35. doi:10.1002/jhrm.21124. h…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43230/psn-pdf
    July 15, 2014 - Hospital deaths in patients with sepsis from 2 independent cohorts. July 15, 2014 Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90-2. https://psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis-2-independent-cohorts This study used nati…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46316/psn-pdf
    August 02, 2017 - Defending a "never event." August 2, 2017 Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277. https://psnet.ahrq.gov/issue/defending-never-event Surgical fires are considered a never event. This commentary provides an overview of surgical fires, explains element…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44135/psn-pdf
    November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the NHS. November 6, 2015 Francis R. London, UK: Department of Health; February 2015. https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs Staff willingness to raise awareness of problems that could affect patient care is an important indicator of …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44783/psn-pdf
    January 13, 2016 - Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do. January 13, 2016 Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226. https://psnet.ahrq.gov/issue/black-box-thinking-why-most-people-never-learn-their-mistakes-some-do Medicine and aviation are high-risk industries where failu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35495/psn-pdf
    February 22, 2010 - The Patient Safety Institute demonstration project: a model for implementing a local health information infrastructure. February 22, 2010 Classen D, Kanhouwa M, Will D, et al. The patient safety institute demonstration project: a model for implementing a local health information infrastructure. J Healthc Inf Manag…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38213/psn-pdf
    November 12, 2008 - AHRQ announces interest in research on diagnostic errors in ambulatory care settings. November 12, 2008 Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002. https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837676/psn-pdf
    July 13, 2022 - Safety-II and the study of healthcare safety routines: two paths forward for research. July 13, 2022 Rydenfält C. Safety-II and the study of healthcare safety routines: two paths forward for research. J Patient Saf Risk Manag. 2022;27(3):124-128. doi:10.1177/25160435221102129. https://psnet.ahrq.gov/issue/safety-i…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36936/psn-pdf
    September 09, 2011 - Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity. September 9, 2011 Schutz AL, Counte MA, Meurer S. Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity. Health Care Manag…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42559/psn-pdf
    May 28, 2014 - Safeguarding in medication administration: understanding pre-registration nursing students' survey response to patient safety and peer reporting issues. May 28, 2014 Andrew S, Mansour M. Safeguarding in medication administration: understanding pre-registration nursing students' survey response to patient safety an…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74214/psn-pdf
    December 29, 2020 - Racial and ethnic disparities in the treatment of chronic pain. December 29, 2020 Morales ME, Yong RJ. Racial and ethnic disparities in the treatment of chronic pain. Pain Med. 2020;22(1):75-90. doi:10.1093/pm/pnaa427. https://psnet.ahrq.gov/issue/racial-and-ethnic-disparities-treatment-chronic-pain This literatu…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843090/psn-pdf
    January 25, 2023 - Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. January 25, 2023 Westwood R. Kaiser Health News. January 12, 2023. https://psnet.ahrq.gov/issue/bleeding-and-pain-pregnant-woman-louisiana-couldnt-get-answers Lack of access to obstetric care impedes safe treatment for mothers. This story de…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42253/psn-pdf
    May 08, 2013 - Using inpatient hospital discharge data to monitor patient safety events. May 8, 2013 Taylor JA, Pandian RS, Mao L, et al. Using inpatient hospital discharge data to monitor patient safety events. J Healthc Risk Manag. 2013;32(4):26-33. doi:10.1002/jhrm.21107. https://psnet.ahrq.gov/issue/using-inpatient-hospital-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36638/psn-pdf
    January 14, 2011 - Health care work environments, employee satisfaction, and patient safety: care provider perspectives. January 14, 2011 Rathert C, May DR. Health care work environments, employee satisfaction, and patient safety: care provider perspectives. Health Care Manage Rev. 2007;32(1):2-11. https://psnet.ahrq.gov/issue/healt…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37760/psn-pdf
    May 14, 2008 - The role of continuous quality improvement and psychological safety in predicting work-arounds. May 14, 2008 Halbesleben JRB, Rathert C. The role of continuous quality improvement and psychological safety in predicting work-arounds. Health Care Manage Rev. 2008;33(2):134-44. doi:10.1097/01.HMR.0000304505.04932.62.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45606/psn-pdf
    October 27, 2016 - Unprofessional workplace conduct...defining and defusing it. October 27, 2016 MacLean L, Coombs C, Breda K. Unprofessional workplace conduct..defining and defusing it. Nurs Manage. 2016;47(9):30-34. doi:10.1097/01.NUMA.0000491126.68354.be. https://psnet.ahrq.gov/issue/unprofessional-workplace-conductdefining-and-d…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46605/psn-pdf
    January 24, 2018 - The impact of interruptions on medication errors in hospitals: an observational study of nurses. January 24, 2018 Johnson M, Sanchez P, Langdon R, et al. The impact of interruptions on medication errors in hospitals: an observational study of nurses. J Nurs Manag. 2017;25(7):498-507. doi:10.1111/jonm.12486. https:…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34036/psn-pdf
    March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004. March 28, 2005 Department of Veterans Affairs (VA) National Center for Patient Safety https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004 The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48166/psn-pdf
    August 28, 2019 - Doctors can change opioid prescribing habits, but progress comes in small doses. August 28, 2019 Appleby J; Lucas E. https://psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses Efforts to reduce misuse of prescription opioids must draw from public health and behavioral stra…

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