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9321. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73163/psn-pdf
      April 21, 2021 - Implicit bias in healthcare: clinical practice, research and decision making. April 21, 2021 Gopal DP, Chetty U, O'Donnell P, et al. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J. 2021;8(1):40-48. doi:10.7861/fhj.2020-0233. https://psnet.ahrq.gov/issue/implicit-bias…

9322. Maryland/DC Patient Safety Coalition. | PSNet
      psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition
      September 28, 2023 - Multi-use Website Maryland/DC Patient Safety Coalition. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 17, 2011 The Maryland Patient Safety Center facilitates the study …

9323. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44246/psn-pdf
      November 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. November 15, 2016 Boston, MA: National Patient Safety Foundation; 2015. https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm The National Patient Safety Foundation issued these guidelines for improving root cause a…

9324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43496/psn-pdf
      November 01, 2016 - Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions. November 1, 2016 Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF. https://psnet.ahrq.gov/issue/designing-…

9325. Hospitals' bid to heal selves saves thousands. | PSNet
      psnet.ahrq.gov/issue/hospitals-bid-heal-selves-saves-thousands
      February 26, 2025 - Newspaper/Magazine Article Hospitals' bid to heal selves saves thousands. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 28, 2006 This article article reports on the resul…

9326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866272/psn-pdf
      July 10, 2024 - Infection control measure performance in long-term care hospitals and their relationship to Joint Commission accreditation. July 10, 2024 Schmaltz SP, Longo BA, Williams SC. Infection control measure performance in long-term care hospitals and their relationship to Joint Commission accreditation. Jt Comm J Qual Pa…

9327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60707/psn-pdf
      July 22, 2020 - The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. July 22, 2020 Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to an…

9328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836985/psn-pdf
      April 27, 2022 - Standardized assessment of medication reconciliation in post-acute care. April 27, 2022 Fischer SH, Shih RA, McMullen TL, et al. Standardized assessment of medication reconciliation in post? acute care. J Am Geriatr Soc. 2022;70(4):1047-1056. doi:10.1111/jgs.17655. https://psnet.ahrq.gov/issue/standardized-assessm…

9329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47853/psn-pdf
      April 10, 2019 - Does a unit shift report "blackout" period improve patient safety? April 10, 2019 Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8- 10. doi:10.1097/01.NUMA.0000553500.85897.51. https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien…

9330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41464/psn-pdf
      November 26, 2014 - Risk of unintentional overdose with non-prescription acetaminophen products. November 26, 2014 Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3. https://psnet.ahrq.gov/issue/risk-uni…

9331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34729/psn-pdf
      October 31, 2016 - Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. October 31, 2016 Casey SM. Santa Barbara, CA: Aegean; 1998. ISBN 9780963617880. https://psnet.ahrq.gov/issue/set-phasers-stun-and-other-true-tales-design-technology-and-human-error- second-edition This book introduce…

9332. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47193/psn-pdf
      September 05, 2018 - Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review. September 5, 2018 Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care; a narrative review. Saf Health. 2018;4(7). doi:10…

9333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866158/psn-pdf
      June 19, 2024 - Anesthesia-related closed claims in free-standing ambulatory surgery centers. June 19, 2024 Pimentel MPT, Chung S, Ross JM, et al. Anesthesia-related closed claims in free-standing ambulatory surgery centers. Anesth Analg. 2024;139(3):521-531. doi:10.1213/ane.0000000000006700. https://psnet.ahrq.gov/issue/anesthes…

9334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849121/psn-pdf
      May 17, 2023 - Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. May 17, 2023 Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Qual. 2023;12(2):e002020. doi:10.1136/bmjoq-2022-002020. https://psne…

9335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44837/psn-pdf
      February 03, 2016 - Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). February 3, 2016 Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients t…

9336. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47248/psn-pdf
      September 26, 2018 - Frequency and nature of potentially harmful preventable problems in primary care from the patient's perspective with clinician review: a population-level survey in Great Britain. September 26, 2018 Stocks SJ, Donnelly A, Esmail A, et al. Frequency and nature of potentially harmful preventable problems in primary …

9337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45674/psn-pdf
      September 29, 2017 - Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. September 29, 2017 Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy …

9338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73710/psn-pdf
      September 15, 2021 - Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study. September 15, 2021 van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of endometriosis from the patients’ perspective: a focus group study. Diagnos…

9339. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45362/psn-pdf
      January 23, 2017 - Capturing essential information to achieve safe interoperability. January 23, 2017 Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. https://psnet.ahrq.gov/issue/capturing-essential-information-achieve-safe-interoperability T…

9340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854833/psn-pdf
      October 25, 2023 - Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas. October 25, 2023 Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227. https://psnet.ahrq.gov/issue/deficiencies-facility-leaders-respons…