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9021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47960/psn-pdf
      May 15, 2019 - A systematic review of clinical decision support systems for clinical oncology practice. May 15, 2019 Pawloski PA, Brooks GA, Nielsen ME, et al. A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. J Natl Compr Canc Netw. 2019;17(4):331-338. doi:10.6004/jnccn.2018.7104. https://…

9022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60696/psn-pdf
      July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…

9023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35501/psn-pdf
      June 15, 2011 - Ethical issues in patient safety. June 15, 2011 Leape L. Ethical issues in patient safety. Thorac Surg Clin. 2005;15(4):493-501. https://psnet.ahrq.gov/issue/ethical-issues-patient-safety This commentary, written by patient safety expert Lucian Leape, begins with a retrospective view on the birth of patient safety…

9024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34648/psn-pdf
      April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…

9025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47260/psn-pdf
      August 08, 2018 - Building the Case for Health Literacy: Proceedings of a Workshop. August 8, 2018 National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018. ISBN: 9780309474290. https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop Health literacy affects p…

9026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39086/psn-pdf
      May 24, 2015 - Psychiatry morbidity and mortality rounds: implementation and impact. May 24, 2015 Goldman S, Demaso DR, Kemler B. Psychiatry morbidity and mortality rounds: implementation and impact. Acad Psychiatry. 2009;33(5):383-8. doi:10.1176/appi.ap.33.5.383. https://psnet.ahrq.gov/issue/psychiatry-morbidity-and-mortality-r…

9027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45397/psn-pdf
      August 10, 2016 - Many well-known hospitals fail to score high in Medicare rankings. August 10, 2016 Rau J. National Public Radio. July 27, 2016. https://psnet.ahrq.gov/issue/many-well-known-hospitals-fail-score-high-medicare-rankings Although quality rating systems have yet to receive approval across the health care industry, they…

9028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50709/psn-pdf
      December 04, 2019 - Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery December 4, 2019 Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019. doi:10.1053/j.semtcvs.2019.10.011. https://psnet.ah…

9029. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44132/psn-pdf
      May 13, 2015 - Adverse outcomes: why bad things happen to good people. May 13, 2015 Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol. 2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064. https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people This commentary…

9030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35598/psn-pdf
      July 10, 2008 - Residents report on adverse events and their causes. July 10, 2008 Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern Med. 2005;165(22):2607-13. https://psnet.ahrq.gov/issue/residents-report-adverse-events-and-their-causes This survey demonstrated that more tha…

9031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50425/psn-pdf
      September 04, 2019 - Why doctors still offer treatments that may not help. September 4, 2019 Frakt A. New York Times. August 26, 2019. https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper…

9032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40883/psn-pdf
      February 10, 2012 - Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. February 10, 2012 Nakhleh RE, Myers JL, Allen TC, et al. Conse…

9033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47951/psn-pdf
      April 24, 2019 - Safe medication management at ambulatory surgery centers. April 24, 2019 Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442. doi:10.1002/aorn.12635. https://psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers Safe medication use can be challengin…

9034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47708/psn-pdf
      February 13, 2019 - The role of purple pens in learning to prescribe. February 13, 2019 Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach. 2019;16(6):598-603. doi:10.1111/tct.12991. https://psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe Interventions utilizing color as visual c…

9035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837608/psn-pdf
      September 06, 2023 - Harm Caused by Delays in Transferring Patients to the Right Place of Care. September 6, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; August 2023. https://psnet.ahrq.gov/issue/harm-caused-delays-transferring-patients-right-place-care Handoffs between prehospital emergency medical services (EMS) pro…

9036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851653/psn-pdf
      July 26, 2023 - Content analysis of nurses' reflections on medication errors in a regional hospital. July 26, 2023 Issacs AN, RAYMOND A, KENT B. Content analysis of nurses’ reflections on medication errors in a regional hospital. Contemp Nurse. 2023;59(3):202-213. doi:10.1080/10376178.2023.2220432. https://psnet.ahrq.gov/issue/co…

9037. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38062/psn-pdf
      March 04, 2011 - Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions. March 4, 2011 Scanlon D, Lindrooth R, Christianson JB. Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions. Health Serv Res. 2008;43(5 Pt 2):1849-68. doi:10.1111/j.1…

9038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43219/psn-pdf
      January 01, 2015 - Developing a reporting and tracking tool for nursing student errors and near misses. May 28, 2014 Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4. https://psnet.ahrq.gov/issue/developing-repor…

9039. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44227/psn-pdf
      November 19, 2018 - A scholarly pathway in quality improvement and patient safety. November 19, 2018 Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med. 2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772. https://psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety…

9040. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47871/psn-pdf
      March 27, 2019 - Closing the disclosure gap: medical errors in pediatrics. March 27, 2019 Lin M, Famiglietti H. Closing the Disclosure Gap: Medical Errors in Pediatrics. Pediatrics. 2019;143(4). doi:10.1542/peds.2019-0221. https://psnet.ahrq.gov/issue/closing-disclosure-gap-medical-errors-pediatrics Disclosure of errors and advers…