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6481. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848082/psn-pdf
      April 26, 2023 - Adopting high reliability organization principles to lead a large scale clinical transformation. April 26, 2023 Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;36(4):241-245. doi:10.1177/08404704231…

6482. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44657/psn-pdf
      November 11, 2015 - Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. November 11, 2015 Bruno MA, Walker EA, Abujudeh H. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics. 2015;35(6):…

6483. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60261/psn-pdf
      April 22, 2020 - Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23- 27, 2020. April 22, 2020 Washington DC: Office of the Inspector General; April 3, 2020. Report no. OEI-06-20-00300. https://psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-…

6484. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74005/psn-pdf
      October 27, 2021 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, October 27, 2021 Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned. A…

6485. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48174/psn-pdf
      January 01, 2020 - The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions among older surgeons. August 21, 2019 Sherwood R, Bismark M. The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions among olde…

6486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843321/psn-pdf
      February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023 ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4. https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event- reach-patient …

6487. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46079/psn-pdf
      June 28, 2017 - Death due to pharmacy compounding error reinforces need for safety focus. June 28, 2017 ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4. https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus Compounding pharmacies prepare medicines for patients that a…

6488. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48013/psn-pdf
      May 29, 2019 - Economic outcomes associated with safety interventions by a pharmacist–adjudicated prior authorization consult service. May 29, 2019 Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…

6489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44466/psn-pdf
      September 16, 2015 - Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. September 16, 2015 Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a re…

6490. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47975/psn-pdf
      May 29, 2019 - Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice. May 29, 2019 London, UK: Royal College of Surgeons of England; 2019. https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice Introducing innovations in practice involves taking calculated ri…

6491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46474/psn-pdf
      November 08, 2017 - Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. November 8, 2017 St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017. https://psnet.ahrq.gov/issue/cle…

6492. Supplies/Surge Capacity Potential | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/shuttered/toolkitchecklist/supplsurge.html
      July 01, 2018 - Supplies/Surge Capacity Potential Partially Shuttered Hospital Facility Walk-through Date: Location: Team member: Title: Affiliation: Overall Findings and Recommendations For each of the statements below, circle the scenario(s)—…

6493. Security/Surge Capacity Potential | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/shuttered/toolkitchecklist/secsurge.html
      July 01, 2018 - Security/Surge Capacity Potential Partially Shuttered Hospital Facility Walk-through Date: Location: Team member: Title: Affiliation: Overall Findings and Recommendations For each of the statements below, circle the scenario(s)—if…

6494. Gas and Ventilation/Surge Capacity Potential | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/shuttered/toolkitchecklist/gasvsurge.html
      July 01, 2018 - Gas and Ventilation/Surge Capacity Potential Partially Shuttered Hospital Facility Walk-through Date: Location: Team member: Title: Affiliation: Overall Findings and Recommendations For each of the statements below, circle the sce…

6495. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73568/psn-pdf
      August 04, 2021 - Coping strategies in health care providers as second victims: a systematic review. August 4, 2021 Kappes M, Romero?García M, Delgado?Hito P. Coping strategies in health care providers as second victims: a systematic review. Int Nurs Rev. 2021;68(4):471-481. doi:10.1111/inr.12694. https://psnet.ahrq.gov/issue/copin…

6496. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47279/psn-pdf
      July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the Home. July 23, 2018 Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence ass…

6497. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48115/psn-pdf
      July 31, 2019 - Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice? July 31, 2019 Kelcikova S, Mazuchova L, Bielena L, et al. Flawed self-assessment in hand hygiene: A major contributor to infections in clinical practice? J Clin Nurs. 2019;28(11-12):2265-2275. doi:10.1111/jocn.14823. ht…

6498. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844783/psn-pdf
      September 04, 2019 - A lethal hidden curriculum—death of a medical student from opioid use disorder. September 4, 2019 Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537. https://psnet.ahrq.gov/issue/lethal-hidden-…

6499. National Action Plans | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/national-action-plans.html
      February 01, 2018 - National Action Plans The work of AHRQ and other Federal agencies is guided by work groups, committees, investigators and expert advisors who contribute to reports on specific topics that impact health care. National Action Plans National Action Plans are developed with expert input to provide a framework f…

6500. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73462/psn-pdf
      July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. July 7, 2021 Abela G. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. J Tissue Viability. 2021;30(3):339-345. doi:10.1016/j.jtv.2021.04.00…