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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37368/psn-pdf
    January 10, 2017 - Effective implementation of work-hour limits and systemic improvements. January 10, 2017 Landrigan CP, Czeisler CA, Barger LK, et al. Effective implementation of work-hour limits and systemic improvements. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):19-29. https://psnet.ahrq.gov/issue/effective-implementation-wo…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838251/psn-pdf
    October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. October 5, 2022 Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840170/psn-pdf
    November 16, 2022 - Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA). November 16, 2022 Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672. https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38142/psn-pdf
    April 30, 2014 - Medical error disclosure among pediatricians: choosing carefully what we might say to parents. April 30, 2014 Loren DJ, Klein EJ, Garbutt J, et al. Medical Error Disclosure Among Pediatricians. Arch Pediatr Adolesc Med. 2008;162(10):922-927. doi:10.1001/archpedi.162.10.922. https://psnet.ahrq.gov/issue/medical-err…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42835/psn-pdf
    April 21, 2015 - Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. April 21, 2015 Millar R, Mannion R, Freeman T, et al. Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. Milbank Q. 2013;91(4):7…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47282/psn-pdf
    August 08, 2018 - Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors. August 8, 2018 Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000312. doi:10.1136/bmjoq-2017-000312. ht…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42113/psn-pdf
    March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. March 20, 2013 Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008. https:/…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40448/psn-pdf
    September 19, 2016 - Health care workers as second victims of medical errors. September 19, 2016 Edrees HH, Paine LA, Feroli R, et al. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011;121(4):101-108. https://psnet.ahrq.gov/issue/health-care-workers-second-victims-medical-errors Medical errors can have a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45216/psn-pdf
    June 08, 2016 - Ambulatory computerized prescribing and preventable adverse drug events. June 8, 2016 Overhage JM, Gandhi TK, Hope C, et al. Ambulatory Computerized Prescribing and Preventable Adverse Drug Events. J Patient Saf. 2016;12(2):69-74. doi:10.1097/PTS.0000000000000194. https://psnet.ahrq.gov/issue/ambulatory-computeriz…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865973/psn-pdf
    May 29, 2024 - Physician antipsychotic overprescribing letters and cognitive, behavioral, and physical health outcomes among people with dementia: a secondary analysis of a randomized clinical trial. May 29, 2024 Harnisch M, Barnett ML, Coussens S, et al. Physician antipsychotic overprescribing letters and cognitive, behavioral…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35611/psn-pdf
    June 23, 2010 - Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. June 23, 2010 Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and d…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39800/psn-pdf
    January 19, 2011 - Medication errors in paediatric outpatients. January 19, 2011 Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf. 2010;19(6). doi:10.1136/qshc.2008.031179. https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients Pediatric medication errors are common …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44042/psn-pdf
    November 03, 2015 - Deployment of rapid response teams by 31 hospitals in a statewide collaborative. November 3, 2015 Stolldorf DP, Jones CB. Deployment of rapid response teams by 31 hospitals in a statewide collaborative. Jt Comm J Qual Patient Saf. 2015;41(4):186-191. https://psnet.ahrq.gov/issue/deployment-rapid-response-teams-31-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45037/psn-pdf
    February 15, 2017 - Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. February 15, 2017 Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Public Health. 2016;135:75-82. doi:10…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47313/psn-pdf
    September 12, 2018 - The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty. September 12, 2018 Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Rooms" Does Not Compromise Out…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36279/psn-pdf
    May 27, 2011 - Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders. May 27, 2011 Palen TE, Raebel MA, Lyons E, et al. Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders. Am J Manag Care. 2006;12(7):389…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38047/psn-pdf
    January 31, 2011 - Single-patient rooms for safe patient-centered hospitals. January 31, 2011 Detsky ME. Single-Patient Rooms for Safe Patient-Centered Hospitals. JAMA. 2008;300(8). doi:10.1001/jama.300.8.954. https://psnet.ahrq.gov/issue/single-patient-rooms-safe-patient-centered-hospitals Providing patient-centered care continues …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37690/psn-pdf
    April 16, 2008 - How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. April 16, 2008 Davis R, Koutantji M, Vincent C. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An expl…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41925/psn-pdf
    November 26, 2014 - Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. November 26, 2014 Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. J Gen Intern Med. 2012;2…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36308/psn-pdf
    January 05, 2017 - A trigger tool to identify adverse events in the intensive care unit.  January 5, 2017 Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s1553- 7250(06)32076-4. https://…

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