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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36773/psn-pdf
    August 21, 2007 - Better: A Surgeon's Notes on Performance. August 21, 2007 Gawande A. New York, NY: Metropolitan; 2007. https://psnet.ahrq.gov/issue/better-surgeons-notes-performance This book includes essays on the social and professional conventions that can affect a physician's ability to provide safe and effective care. Gawand…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38946/psn-pdf
    July 03, 2013 - 2009 Older Adults' Knowledge About Medications That Can Impact Driving. July 3, 2013 MacLennan PA, Owsley C, Rue LW III, McGwin G Jr. Washington, DC: American Automobile Association Foundation for Traffic Safety; August 2009.    https://psnet.ahrq.gov/issue/2009-older-adults-knowledge-about-medications-c…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35018/psn-pdf
    November 28, 2018 - Your company's secret change agents. November 28, 2018 Pascale RT, Sternin J. Your company's secret change agents. Harv Bus Rev. 2005;83(5):72-81, 153. https://psnet.ahrq.gov/issue/your-companys-secret-change-agents The authors describe how to leverage "positive deviants," individuals within an organization who fin…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37463/psn-pdf
    January 06, 2017 - Implementing an MET-based RRS at Toronto General Hospital. January 6, 2017 Warner MB, Reynolds SF. Implementing an MET-based RRS at Toronto General Hospital. Jt Comm J Qual Patient Saf. 2008;34(1):57-9, 1. https://psnet.ahrq.gov/issue/implementing-met-based-rrs-toronto-general-hospital This article describes one …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73548/psn-pdf
    July 27, 2021 - Diagnostic Errors in Primary Care. July 27, 2021 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43032/psn-pdf
    June 17, 2014 - EAU policy on live surgery events. June 17, 2014 Artibani W, Ficarra V, Challacombe BJ, et al. EAU policy on live surgery events. Eur Urol. 2014;66(1):87- 97. doi:10.1016/j.eururo.2014.01.028. https://psnet.ahrq.gov/issue/eau-policy-live-surgery-events The practice of live surgical procedures for educational purpo…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37980/psn-pdf
    October 28, 2009 - Double checking medicines: defence against error or contributory factor? October 28, 2009 Armitage G. Double checking medicines: defence against error or contributory factor? J Eval Clin Pract. 2008;14(4):513-9. https://psnet.ahrq.gov/issue/double-checking-medicines-defence-against-error-or-contributory-factor Th…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38497/psn-pdf
    July 13, 2009 - Social aspects of clinical errors: a discussion paper. July 13, 2009 Richman J, Mason T, Mason-Whitehead E, et al. Social aspects of clinical errors. Int J Nurs Stud. 2009;46(8). doi:10.1016/j.ijnurstu.2009.01.006. https://psnet.ahrq.gov/issue/social-aspects-clinical-errors-discussion-paper This article engages wi…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35124/psn-pdf
    June 29, 2005 - JCAHO proposal for patient-centered care brings concept to mainstream healthcare settings. June 29, 2005 ECRI. Risk Management Reporter. June 2005. https://psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare- settings This commentary provides a definition of patient-cent…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36416/psn-pdf
    December 22, 2010 - A medical error leads to tragedy: how do we inform the patient? December 22, 2010 Baumrucker SJ. A medical error leads to tragedy: how do we inform the patient? Am J Hosp Palliat Care. 2006;23(5):417-21. https://psnet.ahrq.gov/issue/medical-error-leads-tragedy-how-do-we-inform-patient This roundtable discussion p…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41716/psn-pdf
    September 26, 2012 - International advocacy for education and safety. September 26, 2012 McQueen KA, Malviya S, Gathuya ZN, et al. International advocacy for education and safety. Paediatr Anaesth. 2012;22(10):962-8. doi:10.1111/pan.12008. https://psnet.ahrq.gov/issue/international-advocacy-education-and-safety Describing challenges t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38450/psn-pdf
    March 04, 2009 - Variability in pharmacy interpretations of physician prescriptions. March 4, 2009 Wolf MS, Shekelle PG, Choudhry NK, et al. Variability in pharmacy interpretations of physician prescriptions. Med Care. 2009;47(3):370-373. doi:10.1097/MLR.0b013e31818af91a. https://psnet.ahrq.gov/issue/variability-pharmacy-interpret…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39272/psn-pdf
    February 03, 2010 - Patient safety and diagnostic error: tips for your next shift. February 3, 2010 Sinclair D, Croskerry P. Patient safety and diagnostic error: tips for your next shift. Can Fam Physician. 2010;56(1):28-30. https://psnet.ahrq.gov/issue/patient-safety-and-diagnostic-error-tips-your-next-shift Through case examples, …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50900/psn-pdf
    February 12, 2020 - How to "DEAL" with disruptive physician behavior. February 12, 2020 Junga Z, Tritsch A, Singla M. How to “DEAL” With disruptive physician behavior. Gastroenterology. 2019;157(6):1469-1472. doi:10.1053/j.gastro.2019.10.021. https://psnet.ahrq.gov/issue/how-deal-disruptive-physician-behavior In this commentary, the …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34632/psn-pdf
    March 28, 2005 - Keeping Each Patient Safe. March 28, 2005 University of Pittsburgh Schools of the Health Sciences https://psnet.ahrq.gov/issue/keeping-each-patient-safe A collection of three educational modules that address key areas of concern in patient safety. These include protecting patients from hospital-acquired infection,…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36146/psn-pdf
    February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43642/psn-pdf
    November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health. November 5, 2014 London, UK: Frontier Economics Ltd; October 2014. https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health This report provides an overview of evidence on preventabl…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43055/psn-pdf
    May 01, 2017 - AHRQ's Safety Program for Ambulatory Surgery. May 1, 2017 Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May 2017. AHRQ Publication No. 16(17)-0019-1-EF. https://psnet.ahrq.gov/issue/ahrqs-safety-program-ambulatory-surgery This report provides information about a na…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39825/psn-pdf
    June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1-3. https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error This article discusses a case …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35455/psn-pdf
    July 13, 2010 - Urban outpatient views on quality and safety in primary care. July 13, 2010 Dowell D, Manwell LB, Maguire A, et al. Urban outpatient views on quality and safety in primary care. Healthc Q. 2005;8(2):suppl 2-8. https://psnet.ahrq.gov/issue/urban-outpatient-views-quality-and-safety-primary-care In this AHRQ-funded …

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