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8521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43565/psn-pdf
      March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects analysis (FMEA) h…

8522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46733/psn-pdf
      February 14, 2018 - Randomized controlled evaluation of an insulin pen storage policy. February 14, 2018 Gibbs HG, McLernon T, Call R, et al. Randomized controlled evaluation of an insulin pen storage policy. Am J Health Syst Pharm. 2017;74(24):2054-2059. doi:10.2146/ajhp160348. https://psnet.ahrq.gov/issue/randomized-controlled-eval…

8523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34061/psn-pdf
      January 04, 2017 - Patient Safety Leadership WalkRounds. January 4, 2017 Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1). doi:10.1016/s1549-3741(03)29003-1. https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds This study shares the concept of an interventi…

8524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44794/psn-pdf
      May 21, 2019 - Medical Device Use Error: Root Cause Analysis. May 21, 2019 Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis Applying human factors engineering to examine mistakes associated with medical device use can lead …

8525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852286/psn-pdf
      August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023. August 9, 2023 Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262. https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…

8526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854993/psn-pdf
      November 01, 2023 - Building cultures of high reliability: lessons from the high reliability organization paradigm. November 1, 2023 Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2023.03.012. https://psnet.ahrq.g…

8527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867771/psn-pdf
      January 01, 2018 - Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit. January 1, 2018 Agency for Healthcare Research and Quality. Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit. https://psnet.ahrq.gov/issue/community-acquired-pneumonia-clinical-decision-support-implementatio…

8528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43456/psn-pdf
      October 03, 2017 - Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014. October 3, 2017 HR 3230, 113th Congress: 2014. https://psnet.ahrq.gov/issue/veterans-access-care-through-choice-accountability-and-transparency-act- 2014 The Veterans Affairs (VA) health system has both achieved success and str…

8529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34652/psn-pdf
      March 04, 2011 - Epidemiology of medical error. March 4, 2011 Weingart SN, Wilson R, Gibberd RW, et al. Epidemiology of medical error. BMJ. 2000;320(7237):774-7. https://psnet.ahrq.gov/issue/epidemiology-medical-error This article summarizes the epidemiology of medical errors. The authors provide findings from benchmark studies to…

8530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43749/psn-pdf
      December 10, 2014 - Alarm management: first things first: using reliable data to eliminate unnecessary alarms. December 10, 2014 Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45. https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary- alarms Spotlightin…

8531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39960/psn-pdf
      September 19, 2016 - Respectful Management of Serious Clinical Adverse Events. Second Edition. September 19, 2016 Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement; 2011. https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition This white paper e…

8532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47615/psn-pdf
      January 30, 2019 - A Crisis in Health Care: A Call to Action on Physician Burnout. January 30, 2019 Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019. https://psnet.ahrq.g…

8533. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
      psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
      October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It? James M. Naessens, ScD | October 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…

8534. Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. | PSNet
      psnet.ahrq.gov/issue/comparing-catheter-associated-urinary-tract-infection-prevention-programs-between-veterans
      December 21, 2017 - Study Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. Citation Text: Mody L, Greene T, Saint S, et al. Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Betwee…

8535. Awareness of human factors in the operating theatres during the COVID-19 pandemic | PSNet
      psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
      January 13, 2021 - EMERGING INNOVATIONS Awareness of human factors in the operating theatres during the COVID-19 pandemic Citation Text: Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…

8536. University of California, Davis, Health CME/CEU Information | PSNet
      psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
      November 01, 2019 - University of California, Davis, Health CME/CEU Information WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit.  Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…

8537. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. | PSNet
      psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
      June 16, 2021 - EMERGING INNOVATIONS eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. Citation Text: Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…

8538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46952/psn-pdf
      January 01, 2019 - Perspectives on patient and family engagement with reduction in harm: the forgotten voice. December 21, 2018 Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79. doi:10.1097/NCQ.0000000000000333. htt…

8539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60932/psn-pdf
      January 01, 2021 - Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units. September 23, 2020 Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units. BMJ Qual S…

8540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867527/psn-pdf
      January 15, 2025 - Interventions to improve timely cancer diagnosis: an integrative review. January 15, 2025 Graber ML, Winters BD, Matin R, et al. Interventions to improve timely cancer diagnosis: an integrative review. Diagnosis (Berl). 2024;Epub Oct 18. doi:10.1515/dx-2024-0113. https://psnet.ahrq.gov/issue/interventions-improve-…