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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39280/psn-pdf
    February 10, 2010 - Effects of extended work shifts and shift work on patient safety, productivity, and employee health. February 10, 2010 Keller SM. Effects of extended work shifts and shift work on patient safety, productivity, and employee health. AAOHN J. 2009;57(12):497-504. doi:10.3928/08910162-20091124-05. https://psnet.ahrq.g…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38614/psn-pdf
    February 15, 2011 - Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. February 15, 2011 Murray MD, Ritchey ME, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. Arch Intern Med. 2009;169(8):757-63. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44126/psn-pdf
    May 13, 2015 - SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. May 13, 2015 Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173. https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience Implementation of electronic health…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50822/psn-pdf
    January 22, 2020 - Nurses' sleep, work hours, and patient care quality, and safety January 22, 2020 Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320. https://psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety Research provides evidence that sleep deprivation among nurses is a threat to p…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43335/psn-pdf
    July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36615/psn-pdf
    January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities. January 14, 2011 Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1). doi:10.1177/10628…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42677/psn-pdf
    July 16, 2015 - Using "near misses" analysis to prevent wrong-site surgery. July 16, 2015 Yoon RS, Alaia MJ, Hutzler LH, et al. Using "near misses" analysis to prevent wrong-site surgery. J Healthc Qual. 2015;37(2):126-32. doi:10.1111/jhq.12037. https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery B…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39481/psn-pdf
    September 29, 2017 - The natural lifespan of a safety policy: violations and system migration in anaesthesia. September 29, 2017 Maurice G de S, Auroy Y, Vincent CA, et al. The natural lifespan of a safety policy: violations and system migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327-31. doi:10.1136/qshc.2008.029959. htt…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36040/psn-pdf
    June 21, 2006 - Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue]. June 21, 2006 Syed S; Paul JE; Hueftlein M; Kampf M; McLean RF. https://psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdo…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38226/psn-pdf
    February 18, 2011 - Critical events in the lives of interns. February 18, 2011 Ackerman A, Graham M, Schmidt H, et al. Critical events in the lives of interns. J Gen Intern Med. 2009;24(1):27-32. doi:10.1007/s11606-008-0769-8. https://psnet.ahrq.gov/issue/critical-events-lives-interns Resident physicians remain at high risk for burno…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47829/psn-pdf
    March 27, 2019 - The impact of internal service quality on preventable adverse events in hospitals. March 27, 2019 Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758. https://psnet.ahrq.gov/…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36223/psn-pdf
    May 27, 2011 - Prescribers' responses to alerts during medication ordering in the long term care setting. May 27, 2011 Judge J, Field T, DeFlorio M, et al. Prescribers' responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc. 2006;13(4):385-90. https://psnet.ahrq.gov/issue/prescribers-…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43657/psn-pdf
    November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital. November 26, 2014 American Society of Health-System Pharmacists https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837907/psn-pdf
    August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings Medication errors associated with surgery and…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838639/psn-pdf
    October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44846/psn-pdf
    August 31, 2016 - Making health care safer: protect patients from antibiotic resistance. August 31, 2016 CDC; Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance Health care–associated infections (HAI) are a worldwide patient safety problem. This a…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44488/psn-pdf
    September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare- Associated Infections (HAIs). September 16, 2015 Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15- EHC020-EF. https://p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41838/psn-pdf
    December 04, 2016 - Modern palliative radiation treatment: do complexity and workload contribute to medical errors? December 4, 2016 D'Souza N, Holden L, Robson S, et al. Modern palliative radiation treatment: do complexity and workload contribute to medical errors? Int J Radiat Oncol Biol Phys. 2012;84(1):e43-8. doi:10.1016/j.ijrobp…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45386/psn-pdf
    November 23, 2016 - Balancing doctor egos and errors. November 23, 2016 Sweeney JF. Medical Economics. November 10, 2016. https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors Disclosure and candor with patients after a medical error has gained support from organizations, clinicians, and patients. This magazine article discus…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41051/psn-pdf
    February 20, 2012 - What do patients and relatives know about problems and failures in care? February 20, 2012 Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100. https://psnet.ahrq.gov/issue/what-do-patients-and…

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