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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46291/psn-pdf
    July 26, 2017 - Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm. July 26, 2017 van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration erro…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845353/psn-pdf
    March 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. March 1, 2023 Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52. https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72473/psn-pdf
    January 01, 2021 - Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. November 18, 2020 Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865930/psn-pdf
    May 22, 2024 - Operational failures in general practice: a consensus- building study on the priorities for improvement. May 22, 2024 Sinnott C, Alboksmaty A, Moxey JM, et al. Operational failures in general practice: a consensus-building study on the priorities for improvement. Br J Gen Pract. 2024;74(742):e339-e346. doi:10.3399…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45192/psn-pdf
    December 04, 2016 - Evidence summary and recommendations for improved communication during care transitions. December 4, 2016 Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230. https://psnet.ahrq.gov/iss…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851651/psn-pdf
    July 26, 2023 - Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. July 26, 2023 Gur-Arieh S, Mendlovic S, Rozenblum R, et al. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. J Patient Saf. 2023…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46255/psn-pdf
    September 06, 2017 - Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities. September 6, 2017 Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities The ambulatory env…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37585/psn-pdf
    April 29, 2010 - Medication errors involving patient-controlled analgesia.   April 29, 2010 Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194. https://psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-a…
  9. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
    July 01, 2023 - Labor and Delivery Unit Staff Safety Assessment AHRQ Safety Program for Perinatal Care Purpose: To tap into the knowledge and experiences of labor and delivery (L&D) providers and other clinical and nonclinical staff (e.g., health unit coordinators and environmental services personnel) to find ou…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863753/psn-pdf
    March 06, 2024 - Towards a common framework to support decision- making in high-risk, low-time environments. March 6, 2024 Launder D, Penney G. Towards a common framework to support decision?making in high?risk, low?time environments. J Contin Crisis Manag. 2023;31(4):862-876. doi:10.1111/1468-5973.12487. https://psnet.ahrq.gov/is…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45836/psn-pdf
    July 02, 2017 - Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record. July 2, 2017 Bastawrous S, Carney B. Improving Patient Safety: Avoiding Unread Imaging Exams in the National VA Enterprise Electronic Health Record. J Digit Imaging. 2017;30(3):309-313. doi:10.1007/s10278…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41045/psn-pdf
    July 02, 2014 - Relating faults in diagnostic reasoning with diagnostic errors and patient harm. July 2, 2014 Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6. https://psnet.ahrq.gov/issue/relating-fau…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43141/psn-pdf
    April 30, 2014 - Engaging residents and fellows to improve institution- wide quality: the first six years of a novel financial incentive program. April 30, 2014 Vidyarthi A, Green AL, Rosenbluth G, et al. Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865972/psn-pdf
    May 29, 2024 - Development and evaluation of patient safety interventions: perspectives of operational safety leaders and patient safety organizations. May 29, 2024 Gomes KM, Handley J, Pruitt ZM, et al. Development and evaluation of patient safety interventions: perspectives of operational safety leaders and patient safety orga…
  15. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-19.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 1.19. Major Factors that Inhibit Lean Success at LHC Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44033/psn-pdf
    April 22, 2015 - Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. April 22, 2015 Wang H-F, Jin J-F, Feng X-Q, et al. Quality improv…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837148/psn-pdf
    May 18, 2022 - Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study. May 18, 2022 Tate K, McLane P, Reid C, et al. Assessing quality of older persons’ emergency transitions between long- term and acute care settings: a proof-of-concept study. BMJ Open Qual.…
  18. www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
    March 01, 2017 - T.E.A.M.S. infographic AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Culture consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes, and staff satisfaction. Culture influences how change can occur. T Team Formation The most effective…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865592/psn-pdf
    April 17, 2024 - Associations between organizational communication and patients' experience of prolonged emotional impact following medical errors. April 17, 2024 Sokol-Hessner L, Dechen T, Folcarelli P, et al. Associations between organizational communication and patients' experience of prolonged emotional impact following medica…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836929/psn-pdf
    April 13, 2022 - The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project. April 13, 2022 Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid review for the Consensus Development Project. Nurs Open. …