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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33934/psn-pdf
    March 02, 2011 - A hospitalization from hell: a patient's perspective on quality. March 2, 2011 Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33- 39. https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality The author shares the unique perspectives of…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45581/psn-pdf
    October 19, 2016 - Reducing diagnostic errors. October 19, 2016 Gittlen S. HealthLeaders Media. October 1, 2016. https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0 The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance diagnosis. This news article reports how health systems, a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41685/psn-pdf
    July 02, 2014 - Faculty member review and feedback using a sign-out checklist: improving intern written sign-out. July 2, 2014 Bump GM, Bost JE, Buranosky R, et al. Faculty member review and feedback using a sign-out checklist: improving intern written sign-out. Acad Med. 2012;87(8):1125-31. doi:10.1097/ACM.0b013e31825d1215. http…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46322/psn-pdf
    August 02, 2017 - Sophisticated digital aids could help determine what ails you. August 2, 2017 Maron DF. Scientific American. July 21, 2017. https://psnet.ahrq.gov/issue/sophisticated-digital-aids-could-help-determine-what-ails-you Clinical decision support systems are a key strategy to improve diagnostic accuracy. This magazine a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42660/psn-pdf
    October 16, 2013 - Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. October 16, 2013 Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. Acad…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865345/psn-pdf
    March 27, 2024 - The limits of clinician vigilance as an AI safety bulwark. March 27, 2024 Adler-Milstein J, Redelmeier DA, Wachter RM. The limits of clinician vigilance as an AI safety bulwark. JAMA. 2024;331(14):1173-1174. doi:10.1001/jama.2024.3620. https://psnet.ahrq.gov/issue/limits-clinician-vigilance-ai-safety-bulwark Human…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44041/psn-pdf
    April 01, 2015 - Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. April 1, 2015 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015 https://psnet.ahrq.gov/issue/pot…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35383/psn-pdf
    January 02, 2017 - North Mississippi Medical Center: a focus on quality, safety, and financial critical success factors. January 2, 2017 Murphree J, Englert J, Koch K, et al. North Mississippi Medical Center: a focus on quality, safety, and financial critical success factors. Jt Comm J Qual Patient Saf. 2005;31(10):545-53. https://p…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50867/psn-pdf
    February 05, 2020 - Cognitive testing of older clinicians prior to recredentialing. February 5, 2020 Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA. 2020;323(2):179-180. doi:10.1001/jama.2019.18665. https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing In an…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38261/psn-pdf
    December 03, 2008 - Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. December 3, 2008 Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. Arch Pathol Lab Med. 2008;132(11):1792-5…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43464/psn-pdf
    August 27, 2014 - Using pharmacists to optimize patient outcomes and costs in the ED. August 27, 2014 Jacknin G, Nakamura T, Smally AJ, et al. Using pharmacists to optimize patient outcomes and costs in the ED. Am J Emerg Med. 2014;32(6):673-7. doi:10.1016/j.ajem.2013.11.031. https://psnet.ahrq.gov/issue/using-pharmacists-optimize-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46963/psn-pdf
    April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42872/psn-pdf
    December 30, 2014 - Errors in after-hours phone consultations: a simulation study. December 30, 2014 Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243. https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43759/psn-pdf
    September 29, 2017 - Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. September 29, 2017 Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274-286. doi:10.1001/jamainte…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47128/psn-pdf
    October 13, 2018 - Matt's story: learning from heartbreak. October 13, 2018 Miller K, Dastoli A. Matt's story: learning from heartbreak. Int J Qual Health Care. 2018;30(8):654-657. doi:10.1093/intqhc/mzy076. https://psnet.ahrq.gov/issue/matts-story-learning-heartbreak Medical error affects the lives of patients, families, and member…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73539/psn-pdf
    July 28, 2021 - Developing critical thinking skills for delivering optimal care July 28, 2021 Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi:10.1111/imj.15272. https://psnet.ahrq.gov/issue/developing-critical-thinking-skills-delivering-o…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41394/psn-pdf
    December 29, 2014 - An adverse event screening tool based on routinely collected hospital-acquired diagnoses. December 29, 2014 Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10.1093/intqhc/mzs007. https://p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46927/psn-pdf
    April 04, 2018 - Clinician Well-Being Knowledge Hub. April 4, 2018 Washington, DC: National Academy of Medicine. https://psnet.ahrq.gov/issue/clinician-well-being-knowledge-hub Clinician burnout can detract from individual wellness, patient safety, and organizational health. This website serves as a companion to a collaborative ef…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47620/psn-pdf
    January 16, 2019 - Factors underlying suboptimal diagnostic performance in physicians under time pressure. January 16, 2019 ALQahtani DA, Rotgans JI, Mamede S, et al. Factors underlying suboptimal diagnostic performance in physicians under time pressure. Med Educ. 2018;52(12):1288-1298. doi:10.1111/medu.13686. https://psnet.ahrq.gov…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45647/psn-pdf
    February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us. February 22, 2017 Lewis M. Nautilus. February 9, 2017. https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us Physicians' decision-making can be diminished when they are tired, distracted, or too n…