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9841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854986/psn-pdf
      November 01, 2023 - Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report. November 1, 2023 Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more reliable system to monitor test re…

9842. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47735/psn-pdf
      June 24, 2019 - The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. June 24, 2019 Boston, MA: Betsy Lehman Center for Patient Safety; June 2019. https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead- way-patient-safety The Betsy L…

9843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47812/psn-pdf
      April 17, 2019 - Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England. April 17, 2019 Lawton R, Robinson O, Harrison R, et al. Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette s…

9844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45118/psn-pdf
      January 23, 2017 - Cluster randomized trial to evaluate the impact of team training on surgical outcomes. January 23, 2017 Duclos A, Peix JL, Piriou V, et al. Cluster randomized trial to evaluate the impact of team training on surgical outcomes. Br J Surg. 2016;103(13):1804-1814. doi:10.1002/bjs.10295. https://psnet.ahrq.gov/issue/c…

9845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47401/psn-pdf
      January 01, 2019 - We want to know: patient comfort speaking up about breakdowns in care and patient experience. October 17, 2018 Fisher K, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experience. BMJ Qual Saf. 2019;28(3):190-197. doi:10.1136/bmjqs-2018-008159. http…

9846. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41031/psn-pdf
      February 10, 2012 - Is patient safety improving? National trends in patient safety indicators: 1998–2007. February 10, 2012 Downey JR, Hernandez-Boussard T, Banka G, et al. Is patient safety improving? National trends in patient safety indicators: 1998-2007. Health Serv Res. 2012;47(1 Pt 2):414-30. doi:10.1111/j.1475- 6773.2011.01361…

9847. Abbott Diabetes Care blood glucose meters. | PSNet
      psnet.ahrq.gov/issue/abbott-diabetes-care-blood-glucose-meters
      May 04, 2022 - Government Resource Abbott Diabetes Care blood glucose meters. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL November 9, 2005 This announcement alerts patients and practition…

9848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41266/psn-pdf
      January 03, 2017 - Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. January 3, 2017 Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual P…

9849. Failure Mode and Effect Analysis (FMEA) | PSNet
      psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
      September 13, 2021 - Failure Mode and Effect Analysis (FMEA) September 13, 2021 Anonymous (not verified) A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an…

9850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37768/psn-pdf
      April 27, 2010 - The wisdom and justice of not paying for "preventable complications." April 27, 2010 Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197. https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…

9851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41816/psn-pdf
      September 26, 2016 - Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. September 26, 2016 Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. BMJ Qual Saf. 2012;…

9852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43773/psn-pdf
      May 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. May 1, 2015 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. …

9853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41568/psn-pdf
      April 05, 2013 - Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. April 5, 2013 Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…

9854. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40675/psn-pdf
      November 28, 2016 - Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study. November 28, 2016 Iedema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: t…

9855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42736/psn-pdf
      October 31, 2014 - Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. October 31, 2014 Vinden C, Nash DM, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;310(17):1837-4…

9856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73252/psn-pdf
      January 01, 2022 - Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. May 12, 2021 Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…

9857. Resilient Health Care Society. | PSNet
      psnet.ahrq.gov/issue/resilient-health-care-society
      October 09, 2019 - Multi-use Website Resilient Health Care Society. Citation Text: Resilient Health Care Society. Sweden. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL Novem…

9858. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43723/psn-pdf
      October 03, 2017 - Shining a Light: Safer Health Care Through Transparency. October 3, 2017 Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015. https://psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency Health care has historically treated data as something to be safeguarded rat…

9859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37613/psn-pdf
      March 12, 2008 - Implementing patient safety interventions in your hospital: what to try and what to avoid. March 12, 2008 Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007. https://psnet.a…

9860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40483/psn-pdf
      September 20, 2011 - Advancing the science of patient safety. September 20, 2011 Shekelle PG, Pronovost P, Wachter R, et al. Advancing the science of patient safety. Ann Intern Med. 2011;154(10):693-6. doi:10.7326/0003-4819-154-10-201105170-00011. https://psnet.ahrq.gov/issue/advancing-science-patient-safety Research on patient safety…