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7641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43422/psn-pdf
      August 06, 2014 - Core Entrustable Professional Activities for Entering Residency. August 6, 2014 Washington, DC: Association of American Medical Colleges; 2014. https://psnet.ahrq.gov/issue/core-entrustable-professional-activities-entering-residency Studies have revealed a gap between what residents are expected to know and how pr…

7642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37495/psn-pdf
      September 27, 2016 - Emergency department communication links and patterns. September 27, 2016 Fairbanks RJ, Bisantz A, Sunm M. Emergency department communication links and patterns. Ann Emerg Med. 2007;50(4):396-406. https://psnet.ahrq.gov/issue/emergency-department-communication-links-and-patterns This study used link analysis tech…

7643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40952/psn-pdf
      December 07, 2011 - Hospital quality and patient safety competencies: development, description, and recommendations for use. December 7, 2011 O'Leary KJ, Afsar-Manesh N, Budnitz T, et al. Hospital quality and patient safety competencies: Development, description, and recommendations for use. J Hosp Med. 2011;6(9). doi:10.1002/jhm.937.…

7644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44013/psn-pdf
      March 25, 2015 - The effect of hospitalist discontinuity on adverse events. March 25, 2015 O'Leary KJ, Turner J, Christensen N, et al. The effect of hospitalist discontinuity on adverse events. J Hosp Med. 2015;10(3):147-51. doi:10.1002/jhm.2308. https://psnet.ahrq.gov/issue/effect-hospitalist-discontinuity-adverse-events Clinicia…

7645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72713/psn-pdf
      February 03, 2021 - Patient/Family Crisis Hotline. February 3, 2021 Sorry Works!  https://psnet.ahrq.gov/issue/patientfamily-crisis-hotline Patients and families experiencing medical error may not always have access to the support needed to navigate the system to inform improvements and receive appropriate restitution. This hotl…

7646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36464/psn-pdf
      January 07, 2011 - Establishing a rapid response team (RRT) in an academic hospital: one year's experience. January 7, 2011 King E, Horvath R, Shulkin DJ. Establishing a rapid response team (RRT) in an academic hospital: One year's experience. J Hosp Med. 2006;1(5). doi:10.1002/jhm.114. https://psnet.ahrq.gov/issue/establishing-rapi…

7647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41073/psn-pdf
      January 18, 2012 - Quality improvement in medical education: current state and future directions. January 18, 2012 Wong BM, Levinson W, Shojania KG. Quality improvement in medical education: current state and future directions. Med Educ. 2012;46(1):107-19. doi:10.1111/j.1365-2923.2011.04154.x. https://psnet.ahrq.gov/issue/quality-im…

7648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44429/psn-pdf
      May 10, 2016 - Teaching Clinical Reasoning. May 10, 2016 Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Philadelphia, PA: American College of Physicians; 2015. ISBN: 9781938921056. https://psnet.ahrq.gov/issue/teaching-clinical-reasoning Diagnostic errors are often attributed to clinicians' cognitive biases. This publication prov…

7649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44441/psn-pdf
      August 26, 2015 - Preventing Falls With Injury. August 26, 2015 Joint Commission Center for Transforming Healthcare; TST. https://psnet.ahrq.gov/issue/preventing-falls-injury Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations de…

7650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73173/psn-pdf
      April 21, 2021 - Racism and Health. April 21, 2021 Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/racism-and-health Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This US Centers for Disease Control and Prevention (CDC) initiative provides access to …

7651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44226/psn-pdf
      November 03, 2015 - The Patient Survival Handbook. November 3, 2015 Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015. https://psnet.ahrq.gov/issue/patient-survival-handbook Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk…

7652. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47966/psn-pdf
      May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …

7653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40161/psn-pdf
      January 19, 2011 - 2010 John M. Eisenberg Patient Safety and Quality Award Recipients. January 19, 2011 Joint Commission. January 12, 2011. https://psnet.ahrq.gov/issue/2010-john-m-eisenberg-patient-safety-and-quality-award-recipients The Eisenberg Award honors individuals and organizations who have made vital accomplishments in im…

7654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37584/psn-pdf
      March 05, 2008 - Prescribing errors in a pediatric emergency department. March 5, 2008 Rinke ML, Moon M, Clark J, et al. Prescribing errors in a pediatric emergency department. Pediatr Emerg Care. 2008;24(1):1-8. doi:10.1097/pec.0b013e31815f6f6c. https://psnet.ahrq.gov/issue/prescribing-errors-pediatric-emergency-department Pediat…

7655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37605/psn-pdf
      February 22, 2010 - Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims. February 22, 2010 Wojcieszak D, Saxton JW, Finkelstein MM. Bloomington, IN: AuthorHouse; 2010. https://psnet.ahrq.gov/issue/sorry-works-20-disclosure-apology-and-relationships-prevent-medical- malpractice-claims This manu…

7656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72862/psn-pdf
      March 17, 2021 - Cutaneous Procedures Adverse Events Reporting (CAPER). March 17, 2021 The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology. https://psnet.ahrq.gov/issue/cutaneous-procedures-adverse-events-reporting-caper Voluntary reporting systems collect adverse ev…

7657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37714/psn-pdf
      July 24, 2013 - Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. July 24, 2013 PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.  https://psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects- analysis This failure mode and effects anal…

7658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60923/psn-pdf
      September 16, 2020 - Considering the safety and quality of artificial intelligence in health care. September 16, 2020 Ross P, Spates K. Considering the Safety and Quality of Artificial Intelligence in Health Care. Jt Comm J Qual Patient Saf. 2020;46(10):596-599. doi:10.1016/j.jcjq.2020.08.002. https://psnet.ahrq.gov/issue/considering-…

7659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50663/psn-pdf
      November 13, 2019 - Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge. November 13, 2019 Farnborough, UK: Healthcare Safety Investigation Branch; October 2019. https://psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems- and-safe-discharge Des…

7660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40464/psn-pdf
      June 10, 2018 - Multiple latent failures align to allow a serious drug interaction to harm a patient. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3. https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient Detailing a case in which latent failures…