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9721. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38831/psn-pdf
      August 05, 2009 - Rural hospital information technology implementation for safety and quality improvement: lessons learned. August 5, 2009 Tietze MF, Williams J, Galimbertti M. Rural hospital information technology implementation for safety and quality improvement: lessons learned. Comput Inform Nurs. 2009;27(4):206-14. doi:10.1097…

9722. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44597/psn-pdf
      October 28, 2015 - Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance. October 28, 2015 Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352. https://psnet.ahrq.gov/…

9723. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37631/psn-pdf
      May 18, 2015 - The science of improvement. May 18, 2015 Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-4. doi:10.1001/jama.299.10.1182. https://psnet.ahrq.gov/issue/science-improvement This commentary by Dr. Donald Berwick, president of the Institute for Healthcare Improvement, addresses the growing tension betw…

9724. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866324/psn-pdf
      July 17, 2024 - Total systems safety supports practitioners in partnering with families to protect patients. July 17, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4. https://psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients Patient and family concerns can provide…

9725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43990/psn-pdf
      April 22, 2015 - Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. April 22, 2015 Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual Saf. 2015;24(5):303-10. doi:10.1136/bmjqs-2014-003279. h…

9726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42497/psn-pdf
      February 27, 2014 - (How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors. February 27, 2014 Drach-Zahavy A, Somech A, Admi H, et al. (How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication a…

9727. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34706/psn-pdf
      December 23, 2012 - Analysing potential harm in Australian general practice: an incident-monitoring study. December 23, 2012 Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident- monitoring study. Med J Aust. 1998;169(2):73-6. https://psnet.ahrq.gov/issue/analysing-potential-harm…

9728. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37444/psn-pdf
      January 02, 2008 - My brother's keeper: must a physician disclose another's medical error and potential negligence? January 2, 2008 Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10.1016/j.jclinane.2007.05.005. https://p…

9729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34914/psn-pdf
      February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. February 27, 2009 Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3…

9730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39841/psn-pdf
      December 18, 2014 - Emergency department visits for medical device–associated adverse events among children. December 18, 2014 Wang C, Hefflin B, Cope JU, et al. Emergency department visits for medical device-associated adverse events among children. Pediatrics. 2010;126(2):247-59. doi:10.1542/peds.2010-0528. https://psnet.ahrq.gov/i…

9731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45378/psn-pdf
      January 23, 2017 - Quantitative analysis of the content of EMS handoff of critically ill and injured patients to the emergency department. January 23, 2017 Goldberg SA, Porat A, Strother CG, et al. Quantitative Analysis of the Content of EMS Handoff of Critically Ill and Injured Patients to the Emergency Department. Prehosp Emerg Ca…

9732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43024/psn-pdf
      March 05, 2014 - Speaking up for patient safety by hospital-based health care professionals: a literature review. March 5, 2014 Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014;14:61. doi:10.1186/1472-6963-14-61. https://psnet.…

9733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46633/psn-pdf
      November 22, 2017 - The high costs of unnecessary care. November 22, 2017 Carroll AE. The High Costs of Unnecessary Care. JAMA. 2017;318(18):1748-1749. doi:10.1001/jama.2017.16193. https://psnet.ahrq.gov/issue/high-costs-unnecessary-care The provision of unneeded care can result in physical, financial, and psychological harm to patie…

9734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854254/psn-pdf
      October 04, 2023 - Implementing patient safety and quality improvement in dermatology. October 4, 2023 Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67. https://psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-improvement-dermatology Patient safety in dermatology has received increasing …

9735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34771/psn-pdf
      May 06, 2016 - Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. May 6, 2016 Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414. https://psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition According to Weick and Sutcliffe, high…

9736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837739/psn-pdf
      July 27, 2022 - Support methods for healthcare professionals who are second victims: an integrative review. July 27, 2022 Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.  https://psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative- review Healthcare workers who ar…

9737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43058/psn-pdf
      March 26, 2014 - A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency. March 26, 2014 O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency. J Surg Educ. 2014…

9738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40623/psn-pdf
      July 20, 2011 - Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. July 20, 2011 Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011;73(2):217-25. doi:10.1016/j.socscime…

9739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72480/psn-pdf
      January 01, 2021 - Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. November 18, 2020 Watterson TL, Look KA, Steege LM, et al. Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. Res Social Adm Pharm. 2021;17(7):1282-1287. doi:10.1016/j.sapharm.2020.09.012. http…

9740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46324/psn-pdf
      August 09, 2017 - IHI Framework for Improving Joy in Work. August 9, 2017 Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/ihi-framework-improving-joy-work Leadership has a responsibility to establish a culture that fosters staff and clinician well-being as a…