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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38734/psn-pdf
    July 01, 2009 - Safety and efficiency considerations for the introduction of electronic ordering in a blood bank. July 1, 2009 Georgiou A, Greenfield T, Callen J, et al. Safety and efficiency considerations for the introduction of electronic ordering in a blood bank. Arch Pathol Lab Med. 2009;133(6):933-7. doi:10.1043/1543-2165- …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39696/psn-pdf
    January 19, 2011 - Comparison of methods for identifying patients at risk of medication-related harm. January 19, 2011 van Doormaal J, Rommers MK, Kosterink JGW, et al. Comparison of methods for identifying patients at risk of medication-related harm. Qual Saf Health Care. 2010;19(6):e26. doi:10.1136/qshc.2009.033324. https://psnet.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38576/psn-pdf
    April 22, 2009 - A case of mistaken identity: staff input on patient ID errors. April 22, 2009 Ortiz J, Amatucci C. A case of mistaken identity: staff input on patient ID errors. Nurs Manag. 2009;40(4):37-41. doi:10.1097/01.NUMA.0000349689.98615.6d. https://psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38503/psn-pdf
    June 16, 2009 - Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention. June 16, 2009 Di Pentima C, Chan S, Eppes SC, et al. Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and interventi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837798/psn-pdf
    August 10, 2022 - An evolution of reporting: identifying the missing link. August 10, 2022 Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics (Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761. https://psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37857/psn-pdf
    May 26, 2011 - The impact of computerized physician medication order entry in hospitalized patients—a systematic review. May 26, 2011 Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients--a systematic review. Int J Med Inform. 2008;77(6):365-76. https://psnet.a…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73898/psn-pdf
    September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34071/psn-pdf
    February 18, 2011 - A middle ground on public accountability. February 18, 2011 Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med. 2004;350(23):2409-2412. https://psnet.ahrq.gov/issue/middle-ground-public-accountability This commentary discusses the complex interplay between payers, purchasers, pati…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34048/psn-pdf
    May 27, 2011 - Computerized physician order entry: helpful or harmful? May 27, 2011 Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-3. https://psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful The authors critically review the published …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43020/psn-pdf
    May 29, 2014 - Handoff practices in undergraduate medical education. May 29, 2014 Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0. https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education This su…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47056/psn-pdf
    April 20, 2022 - Healthcare Simulation Week. April 20, 2022 Society for Simulation in Healthcare. https://psnet.ahrq.gov/issue/healthcare-simulation-week Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials f…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37196/psn-pdf
    June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg. June 6, 2018 ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4. https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg- and-mg This article analyzes a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39582/psn-pdf
    April 14, 2011 - Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. April 14, 2011 Harris MF, Chan BC, Daniel C, et al. Development and early experience from an intervention to facilitate teamwork between general practices and all…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73327/psn-pdf
    January 25, 2022 - ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur. This asses…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37596/psn-pdf
    May 01, 2016 - Patient Safety Organization (PSO) Program. May 1, 2016 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient care," the Agency for Healthcare Research…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60672/psn-pdf
    July 08, 2020 - The Care We Need July 8, 2020 Washington DC: National Quality Forum; 2020. https://psnet.ahrq.gov/issue/care-we-need This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which f…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35529/psn-pdf
    May 27, 2011 - Case study: identifying potential problems at the human/technical interface in complex clinical systems. May 27, 2011 Caudill-Slosberg M, Weeks WB. Case study: identifying potential problems at the human/technical interface in complex clinical systems. Am J Med Qual. 2005;20(6):353-7. https://psnet.ahrq.gov/issue/…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39615/psn-pdf
    December 17, 2010 - Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. December 17, 2010 Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg Med. 2010;56(6):623-9. doi:10.10…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47847/psn-pdf
    July 10, 2024 - CHPSO Annual Reports. July 10, 2024 California Hospital Patient Safety Organization: Sacramento, CA; 2024. https://psnet.ahrq.gov/issue/chpso-2019-annual-report Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490 members. This report highlights 2023 trends, activit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45269/psn-pdf
    November 18, 2016 - Surgeons' disclosures of clinical adverse events. November 18, 2016 Elwy R, Itani KMF, Bokhour BG, et al. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg. 2016;151(11):1015-1021. doi:10.1001/jamasurg.2016.1787. https://psnet.ahrq.gov/issue/surgeons-disclosures-clinical-adverse-events Even though disclo…

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