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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43868/psn-pdf
    February 04, 2015 - Implementing a standardized safe surgery program reduces serious reportable events. February 4, 2015 Loftus T, Dahl D, OHare B, et al. Implementing a standardized safe surgery program reduces serious reportable events. J Am Coll Surg. 2015;220(1):12-17.e3. doi:10.1016/j.jamcollsurg.2014.09.018. https://psnet.ahrq.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837140/psn-pdf
    May 18, 2022 - Nursing surveillance: a concept analysis May 18, 2022 Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460. doi:10.1111/nuf.12702. https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis Nursing surveillance is an intervention for maintaining patient saf…
  3. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-15.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.15. Major Factors that Inhibited Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Cas…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852803/psn-pdf
    August 23, 2023 - Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. August 23, 2023 Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006. https://psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-sa…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39834/psn-pdf
    July 02, 2014 - Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. July 2, 2014 Young JQ, Niehaus B, Lieu SC, et al. Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. Acad Med. 2010;85(9):1418-24.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39064/psn-pdf
    October 28, 2009 - Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. October 28, 2009 Steinberger DM, Douglas S, Kirschbaum MS. Use of failure mode and effects analysis for proactive identification of communication and handoff failur…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74693/psn-pdf
    January 26, 2022 - Including the reason for use on prescriptions sent to pharmacists: scoping review. January 26, 2022 Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists: scoping review. JMIR Hum Factors. 2021;8(4):e22325. doi:10.2196/22325. https://psnet.ahrq.gov/issue/including-re…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46206/psn-pdf
    August 02, 2017 - Patient safety in dentistry: development of a candidate 'never event' list for primary care. August 2, 2017 Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456. https://psnet.ahrq.gov/issue/patie…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44088/psn-pdf
    May 13, 2015 - Safety culture and care: a program to prevent surgical errors. May 13, 2015 Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002. https://psnet.ahrq.gov/issue/safety-culture-and-care-program-prev…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33890/psn-pdf
    January 04, 2017 - The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety. January 4, 2017 Wachter R, Shojania KG. The faces of errors: a case-based approach to educating providers, policymakers, and the public about patient safety. Jt Comm J Qual Saf. 2004;30(12):665-67…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60626/psn-pdf
    June 24, 2020 - A nursing home’s 64-day Covid siege: ‘They’re all going to die’. June 24, 2020 Barker K. A nursing home’s 64-day Covid siege: ‘They’re all going to die’. New York Times. 2020;June 10. https://psnet.ahrq.gov/issue/nursing-homes-64-day-covid-siege-theyre-all-going-die This feature story describes the COVID-19 experi…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46392/psn-pdf
    October 13, 2018 - The clinical and medicolegal implications of radiology results communication. October 13, 2018 Aryal B, Khorsand DA, Dubinsky TJ. The Clinical and Medicolegal Implications of Radiology Results Communication. Curr Probl Diagn Radiol. 2018;47(5):287-289. doi:10.1067/j.cpradiol.2017.09.009. https://psnet.ahrq.gov/iss…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38996/psn-pdf
    March 04, 2011 - Overcoming barriers to the implementation of a pharmacy bar code scanning system for medication dispensing: a case study. March 4, 2011 Nanji KC, Cina J, Patel N, et al. Overcoming barriers to the implementation of a pharmacy bar code scanning system for medication dispensing: a case study. J Am Med Inform Assoc. …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60034/psn-pdf
    March 11, 2020 - Responding to unprofessional behavior by trainees - a "just culture" framework. March 11, 2020 Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591. https://psnet.ahrq.gov/issue/resp…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47546/psn-pdf
    November 14, 2018 - Why doctors hate their computers. November 14, 2018 Gawande A. New Yorker. November 12, 2018. https://psnet.ahrq.gov/issue/why-doctors-hate-their-computers In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elabo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45846/psn-pdf
    January 07, 2019 - Medication safety in the operating room: literature and expert-based recommendations. January 7, 2019 Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert- based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew379. https://psnet.ahrq.gov/issu…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39618/psn-pdf
    August 03, 2010 - Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. August 3, 2010 Singh H, Hirani K, Kadiyala H, et al. Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. J Clin Oncol. 2010…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837075/psn-pdf
    May 11, 2022 - Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief. May 11, 2022 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. https://psnet.ahrq.gov/issue/lessons-learned-covid-19-pandemic-improve-diagnosis-proceedin…
  19. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-13.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 5.13. Project Team Composition—Pediatric Continuity of Care Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Heal…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43178/psn-pdf
    July 28, 2014 - Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. July 28, 2014 Vincent CA, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining s…