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6621. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73501/psn-pdf
      July 14, 2021 - Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic. July 14, 2021 Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171. https://psnet.ahrq.gov/issue/deficiencie…

6622. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44119/psn-pdf
      September 19, 2016 - Risk managers' descriptions of programs to support second victims after adverse events. September 19, 2016 White AA, Brock DM, McCotter PI, et al. Risk managers' descriptions of programs to support second victims after adverse events. J Healthc Risk Manag. 2015;34(4):30-40. doi:10.1002/jhrm.21169. https://psnet.ah…

6623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848043/psn-pdf
      April 26, 2023 - Tools for establishing a sustainable safety culture within maternity services: a retrospective case study. April 26, 2023 Løland M, Braut GS, Lichtenberg SM, et al. Tools for establishing a sustainable safety culture within maternity services: a retrospective case study. SAGE Open Med. 2023;11:205031212311642. doi…

6624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61077/psn-pdf
      October 28, 2020 - Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital. October 28, 2020 Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.  https://psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-servi…

6625. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47823/psn-pdf
      March 13, 2019 - Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care. March 13, 2019 Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6. https://psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-del…

6626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47541/psn-pdf
      March 04, 2019 - Health outcomes of deprescribing interventions among older residents in nursing homes: a systematic review and meta-analysis. March 4, 2019 Kua C-H, Mak VSL, Lee SWH. Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis. J Amer Med Direct Asso…

6627. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47756/psn-pdf
      February 06, 2019 - Meltdown: Why Our Systems Fail and What We Can Do About It. February 6, 2019 Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632. https://psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it Complex systems are prone to failure. This book provides a multi-indu…

6628. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45798/psn-pdf
      February 01, 2017 - American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. February 1, 2017 Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224(1):59-74. doi:10.…

6629. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47688/psn-pdf
      March 19, 2019 - Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery. March 19, 2019 Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in tho…

6630. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42989/psn-pdf
      May 28, 2014 - Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. May 28, 2014 Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a transcript analysis of communication b…

6631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73320/psn-pdf
      May 26, 2021 - What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study. May 26, 2021 Scantlebury A, Sheard L, Fedell C, et al. What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study. Digit Health. 2021;7:20552…

6632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44028/psn-pdf
      April 01, 2015 - Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. April 1, 2015 Rayo MF, Moffatt-Bruce SD. Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. BMJ Qual Saf. 2015;24(…

6633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853059/psn-pdf
      August 30, 2023 - Anesthesia Risk Alert program: a proactive safety initiative. August 30, 2023 Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005. https://psnet.ahrq.gov/issue/anesthesia-risk-alert-program-pr…

6634. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34055/psn-pdf
      March 07, 2005 - What is driving hospitals' patient-safety efforts? March 7, 2005 Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood). 2004;23(2):103-15. https://psnet.ahrq.gov/issue/what-driving-hospitals-patient-safety-efforts This study evaluated the role professionalism, regulati…

6635. Improvement Data | Agency for Healthcare Research and Quality
      www.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/improvement-data.html
      July 01, 2021 - Quality of Pediatric Hospital-to-Home Transitions Toolkit Improvement Data Previous Page Next Page Table of Contents Quality of Pediatric Hospital-to-Home Transitions Toolkit Introduction Overview About the Measure Key Driver Diagram Quality Improvement Strategies Improvement Data Othe…

6636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60872/psn-pdf
      September 02, 2020 - How incident reporting systems can stimulate social and participative learning: a mixed-methods study. September 2, 2020 de Kam D, Kok J, Grit K, et al. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Health Policy (New York). 2020;124(8):834-841. doi:10.1016/…

6637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74135/psn-pdf
      December 01, 2021 - Communication regarding adverse neonatal birth events: experiences of parents and clinicians. December 1, 2021 Loren DL, Lyerly AD, Lipira L, et al. Communication regarding adverse neonatal birth events: experiences of parents and clinicians. J Patient Saf Risk Manag. 2021;26(5):200-206. doi:10.1177/25160435211017…

6638. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46706/psn-pdf
      March 20, 2018 - Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors. March 20, 2018 Hirschtritt ME, Chan S, Ly WO. Realizing E-Prescribing's Potential to Reduce Outpatient Psychiatric Medication Errors. Psychiatr Serv. 2018;69(2):129-132. doi:10.1176/appi.ps.201700269. https://psnet.ahrq.gov/iss…

6639. Appendix D: Members of the CCRM Expert Panel | Agency for Healthcare Research and Quality
      www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap-apd.html
      July 01, 2013 - Clinical-Community Relationships Evaluation Roadmap Appendix D: Members of the CCRM Expert Panel Previous Page   Table of Contents Clinical-Community Relationships Evaluation Roadmap Executive Summary 1. Introduction and Purpose 2. Priority Questions and Recommendations 3. Conclusion Refer…

6640. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46898/psn-pdf
      April 16, 2019 - TeamSTEPPS: an evidence-based approach to reduce clinical errors threatening safety in outpatient settings: an integrative review. April 16, 2019 Parker AL, Forsythe LL, Kohlmorgen IK. TeamSTEPPS : An evidence-based approach to reduce clinical errors threatening safety in outpatient settings: An integrative review…