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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43681/psn-pdf
    June 03, 2016 - Learning from failure: the need for independent safety investigation in healthcare. June 3, 2016 Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939. https://psnet.ahrq.gov/issue/learning-failure-n…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37912/psn-pdf
    September 25, 2008 - Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. September 25, 2008 Bonis PA, Pickens GT, Rind DM, et al. Association of a clinical knowledge support system wi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47109/psn-pdf
    June 06, 2018 - Principles of automation for patient safety in intensive care: learning from aviation. June 6, 2018 Dominiczak J, Khansa L. Principles of Automation for Patient Safety in Intensive Care: Learning From Aviation. Jt Comm J Qual Patient Saf. 2018;44(6):366-371. doi:10.1016/j.jcjq.2017.11.008. https://psnet.ahrq.gov/i…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866813/psn-pdf
    September 25, 2024 - Peer support to promote surgeon well-being: the APSA program experience. September 25, 2024 Fall F, Hu YY, Walker S, et al. Peer support to promote surgeon well-being: the APSA program experience. J Pediatr Surg. 2024;59(9):1665-1671. doi:10.1016/j.jpedsurg.2023.12.022. https://psnet.ahrq.gov/issue/peer-support-pr…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60303/psn-pdf
    May 06, 2020 - Using safety culture results to guide the merger of four general practices in the UK. May 6, 2020 Lockwood AM, Proulx J, Hill M, et al. Using safety culture results to guide the merger of four general practices in the UK. BMJ Open Qual. 2020;9(1):e000860. doi:10.1136/bmjoq-2019-000860. https://psnet.ahrq.gov/issue…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47761/psn-pdf
    May 22, 2019 - Clinicians' perceptions of opioid error–contributing factors in inpatient palliative care services: a qualitative study. May 22, 2019 Heneka N, Bhattarai P, Shaw T, et al. Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study. Palliat Med. 2019;33(4…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866825/psn-pdf
    September 25, 2024 - Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022. September 25, 2024 Rodrick D, Timashenka A, Umscheid C. Adverse Events Among In-Hospital Medicare Patients In 2021 And 2022. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication no. 24-0084 https://psnet.ahrq.gov/issu…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46190/psn-pdf
    August 17, 2017 - Preventing harm in the ICU—building a culture of safety and engaging patients and families. August 17, 2017 Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537. doi:10.1097/CCM.0000000000002556. ht…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43933/psn-pdf
    March 04, 2015 - How informatics nurses use bar code technology to reduce medication errors. March 4, 2015 Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux). 2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37. https://psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-t…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45041/psn-pdf
    September 28, 2016 - Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy. September 28, 2016 Bhamidipati S, Elliott DJ, Justice EM, et al. Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38091/psn-pdf
    February 18, 2011 - Questionable hospital chart documentation practices by physicians. February 18, 2011 Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6. https://psnet.ahrq.gov/issue/questionable-hospital-cha…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34810/psn-pdf
    February 18, 2011 - Should operations be regionalized? The empirical relation between surgical volume and mortality. February 18, 2011 Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301(25):1364-9. https://psnet.ahrq.gov/issue/should…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842415/psn-pdf
    January 11, 2023 - Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists. January 11, 2023 Heesen M, Steuer C, Wiedemeier P, et al. Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists. J Patient Saf. 2022;18(8):e1226-e1230. doi:10.1097/pts.0000000000001061. https://…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844770/psn-pdf
    September 11, 2019 - Use of "Doctor" badges for physician role identification during clinical training. September 11, 2019 Foote MB, DeFilippis EM, Rome BN, et al. Use of "Doctor" Badges for Physician Role Identification During Clinical Training. JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2019.2416. https://psnet.ahrq.gov/issue/…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74211/psn-pdf
    December 22, 2021 - Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products December 22, 2021 Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.  https://psnet.ahrq.gov/issue/filling-gaps-institute-safe-medication-practices-ismp-do-not-crush-li…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43867/psn-pdf
    March 11, 2015 - Applying fault tree analysis to the prevention of wrong- site surgery. March 11, 2015 Abecassis ZA, McElroy LM, Patel RM, et al. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015;193(1):88-94. doi:10.1016/j.jss.2014.08.062. https://psnet.ahrq.gov/issue/applying-fault-tree-analy…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838920/psn-pdf
    October 26, 2022 - Investigation of mental and physical health of nurses associated with errors in clinical practice. October 26, 2022 Pappa D, Koutelekos I, Evangelou E, et al. Investigation of mental and physical health of nurses associated with errors in clinical practice. Healthcare (Basel). 2022;10(9):1803. doi:10.3390/healthcar…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50448/psn-pdf
    October 09, 2019 - Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden. October 9, 2019 Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healthcare and emergency departments…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837664/psn-pdf
    July 13, 2022 - Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. July 13, 2022 Thirsk LM, Panchuk JT, Stahlke S, et al. Cognitive and implicit biases in nurses' judgment and decision- making: a scoping review. Int J Nurs Stud. 2022;133:104284. doi:10.1016/j.ijnurstu.2022.104284. https://psn…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856631/psn-pdf
    November 29, 2023 - Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to historically marginalized patients. November 29, 2023 Olazo K, Gallagher TH, Sarkar U. Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to historically marginalized patien…

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