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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37414/psn-pdf
    April 19, 2011 - Medical and nursing staff highly value clinical pharmacists in the emergency department. April 19, 2011 Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emergency Medicine Journal. 2007;24(10). doi:10.1136/emj.2006.044313. http…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853445/psn-pdf
    December 15, 2022 - Jake Tapper shares harrowing story of daughter's near- fatal misdiagnosis. December 15, 2022 CNN. December 15, 2022. https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis Diagnostic errors are a recognized cause of preventable patient harm.  This video highlights a teen’…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45808/psn-pdf
    December 19, 2017 - A concept analysis of systems thinking. December 19, 2017 Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196. https://psnet.ahrq.gov/issue/concept-analysis-systems-thinking Systems thinking focuses on enabling an organization t…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41490/psn-pdf
    August 07, 2012 - 2011 John M. Eisenberg Patient Safety and Quality Awards. August 7, 2012 Jt Comm J Qual Patient Saf. 2012;38(7):289-327. https://psnet.ahrq.gov/issue/2011-john-m-eisenberg-patient-safety-and-quality-awards Highlighting the accomplishments of the 2011 recipients of the John M. Eisenberg Patient Safety and Quality …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44905/psn-pdf
    April 27, 2016 - Inpatient housestaff discontinuity of care and patient adverse events. April 27, 2016 Fletcher KE, Singh S, Schapira MM, et al. Inpatient Housestaff Discontinuity of Care and Patient Adverse Events. Am J Med. 2016;129(3):341-7.e21. doi:10.1016/j.amjmed.2015.11.008. https://psnet.ahrq.gov/issue/inpatient-housestaff…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47364/psn-pdf
    October 31, 2018 - AI can't replace doctors. But it can make them better. October 31, 2018 Parikh R. MIT Technol Rev. October 23, 2018. https://psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health ca…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34695/psn-pdf
    June 26, 2015 - Do house officers learn from their mistakes? June 26, 2015 Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-94. https://psnet.ahrq.gov/issue/do-house-officers-learn-their-mistakes The authors report their 1991 survey on medical errors among internal medicine …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837867/psn-pdf
    August 17, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department. August 17, 2022 Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for Healthcare Research and Quality; August 2022. AHRQ Publication No. 22-0026-2-EF. https://psnet.ahrq.gov/issue/distributed-cognition-an…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73098/psn-pdf
    September 07, 2021 - Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief. September 7, 2021 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021. https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41820/psn-pdf
    November 07, 2012 - Serious adverse events from accidental ingestion by children of over-the-counter eye drops and nasal sprays. November 7, 2012 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 25, 2012. https://psnet.ahrq.gov/issue/serious-adverse-events-accidental-ingestion-children-over-counter-ey…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38352/psn-pdf
    June 14, 2011 - Developing a tool for assessing competency in root cause analysis. June 14, 2011 Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual Patient Saf. 2009;35(1):36-42. https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis Root cause anal…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43247/psn-pdf
    August 02, 2015 - Characteristics of medical professional liability claims against internists. August 2, 2015 Mangalmurti SS, Harold JG, Parikh PD, et al. Characteristics of medical professional liability claims against internists. JAMA Intern Med. 2014;174(6):993-5. doi:10.1001/jamainternmed.2014.1116. https://psnet.ahrq.gov/issue…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45370/psn-pdf
    July 27, 2016 - Correct use of inhalers: help patients breathe easier. July 27, 2016 ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6. https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier Patients and clinicians can make medication administration mistakes when new drug delivery mecha…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44392/psn-pdf
    August 12, 2015 - Petty, dangerous, disruptive doctors: watch out! August 12, 2015 Crane ME. Medscape Business of Medicine. July 23, 2015. https://psnet.ahrq.gov/issue/petty-dangerous-disruptive-doctors-watch-out Disruptive behavior among clinicians is a recognized problem that can hinder teamwork and detract from a culture of safe…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40487/psn-pdf
    June 01, 2011 - Developing and testing a tool to measure nurse/physician communication in the intensive care unit. June 1, 2011 Carbo AR, Tess AV, Roy CL, et al. Developing a High-Performance Team Training Framework for Internal Medicine Residents. J Patient Saf. 2011;7(2). doi:10.1097/pts.0b013e31820dbe02. https://psnet.ahrq.gov…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60331/psn-pdf
    May 13, 2020 - How a Doctor Confronts Medical Error. May 13, 2020 People’s Pharmacy.  Show 1209. April 28, 2020. https://psnet.ahrq.gov/issue/how-doctor-confronts-medical-error Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60157/psn-pdf
    March 25, 2020 - Conspicuous by its absence: diagnostic expert testing under uncertainty. March 25, 2020 Dai T, Singh S. Conspicuous by Its absence: diagnostic expert testing under uncertainty. Market Sci. 2020;39(3):540-563. doi:10.1287/mksc.2019.1201. https://psnet.ahrq.gov/issue/conspicuous-its-absence-diagnostic-expert-testing…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46997/psn-pdf
    July 25, 2018 - Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review. July 25, 2018 Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018. https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-healthcare-report-rapid-policy-review Accountability for errors and or…
  19. 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…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839330/psn-pdf
    November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality. November 2, 2022 Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022 https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality The task of performing a …