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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46920/psn-pdf
    August 08, 2018 - Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. August 8, 2018 Krein SL, Mayer J, Harrod M, et al. Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitati…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45815/psn-pdf
    January 25, 2017 - Handoffs: transitions of care for children in the emergency department. January 25, 2017 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837671/psn-pdf
    July 13, 2022 - Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports. July 13, 2022 Kepner S, Adkins JA, Jones RM. Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports. Patient Saf. 2022;4(2):6-17. doi:10.33940/data/2022.6.1. https://psnet.ahrq.gov/issue/long-ter…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849331/psn-pdf
    May 24, 2023 - Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. May 24, 2023 Kepner S, Bingman C, Jones RM. Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. Patient Saf. 2023;5(2):20-31. doi:10.33940/001c.74494. https://psnet.ahrq.gov/issue/long-term-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - The potential for improved teamwork to reduce medical errors in the emergency department. June 24, 2015 Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4. https://ps…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44898/psn-pdf
    November 23, 2016 - Types and patterns of safety concerns in home care: client and family caregiver perspectives. November 23, 2016 Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220. doi:10.1093/intqhc/mzw0…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74005/psn-pdf
    October 27, 2021 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, October 27, 2021 Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned. A…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44344/psn-pdf
    July 22, 2015 - Making healthcare safer by understanding, designing and buying better IT. July 22, 2015 Thimbleby H, Lewis A, Williams J. Making healthcare safer by understanding, designing and buying better IT. Clin Med (Lond). 2015;15(3):258-62. doi:10.7861/clinmedicine.15-3-258. https://psnet.ahrq.gov/issue/making-healthcare-s…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47832/psn-pdf
    February 27, 2019 - Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019 ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24. https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly- overrides-just-cultu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851201/psn-pdf
    July 05, 2023 - ‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care. July 5, 2023 Gammon K. STAT. June 26, 2023. https://psnet.ahrq.gov/issue/i-felt-i-was-dying-how-women-postpartum-depression-fall-through-cracks-us- health-care The maternal mental health crisis results in …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73474/psn-pdf
    July 07, 2021 - Resident and family engagement in medication management in aged care facilities: a systematic review. July 7, 2021 Manias E, Bucknall T, Hutchinson AM, et al. Resident and family engagement in medication management in aged care facilities: a systematic review. Expert Opin Drug Saf. 2021:1-19. doi:10.1080/14740338.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47636/psn-pdf
    December 12, 2018 - Learning from tragedy: the Julia Berg story. December 12, 2018 Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl). 2018;5(4):257-266. doi:10.1515/dx-2018-0067. https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story This commentary provides a clinical review of …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34677/psn-pdf
    February 09, 2011 - Patients' and physicians' attitudes regarding the disclosure of medical errors. February 9, 2011 Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-7. https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regar…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44877/psn-pdf
    April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices. April 27, 2016 Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16- 158. https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and- pre…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47595/psn-pdf
    March 06, 2019 - Approaches and Challenges to Electronically Matching Patients' Records Across Providers. March 6, 2019 Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197. https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across- provid…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35365/psn-pdf
    February 17, 2011 - Accidental deaths, saved lives, and improved quality. February 17, 2011 Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44351/psn-pdf
    October 21, 2015 - Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff. October 21, 2015 Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administrati…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45457/psn-pdf
    September 01, 2016 - Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor. September 1, 2016 Simpson KR, Lyndon A, Davidson LA. Patient Safety Implications of Electronic Alerts and Alarms of Maternal - Fetal Status During Labor. Nurs Womens Health. 2016;20(4):358-66. doi:10.1016/j.nwh.2016.…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34777/psn-pdf
    February 16, 2011 - Systems errors versus physicians' errors: finding the balance in medical education. February 16, 2011 Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education. Acad Med. 1999;74(1):19-22. https://psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-bal…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43108/psn-pdf
    September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report. September 28, 2023 Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene. https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report This annual report summarizes never events in Maryland hospit…

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