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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849136/psn-pdf
    May 17, 2023 - Using morbidity and mortality conferences to drive quality improvement and reduce errors. May 17, 2023 Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17. https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and- reduce-errors Morbidity and mortality (…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47431/psn-pdf
    September 26, 2018 - Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. September 26, 2018 Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90. https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce- pr…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45867/psn-pdf
    April 12, 2017 - The Economics of Patient Safety: Strengthening a Value- based Approach to Reducing Patient Harm at National Level. April 12, 2017 Slawomirski L, Auraaen A, Klazinga N. Organisation for Economic Co-operation and Development: Paris, France; 2017. https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-v…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34657/psn-pdf
    June 14, 2011 - Multidisciplinary approaches to reducing error and risk in a patient care setting. June 14, 2011 Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002;14(4):359-67, viii. https://psnet.ahrq.gov/issue/multidisciplinary-ap…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - The potential for improved teamwork to reduce medical errors in the emergency department. June 24, 2015 Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4. https://ps…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42745/psn-pdf
    October 31, 2014 - Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study. October 31, 2014 Concha OP, Gallego B, Hillman K, et al. Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47455/psn-pdf
    October 31, 2018 - Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. October 31, 2018 Meisenberg BR, Grover J, Campbell C, et al. Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Red…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47651/psn-pdf
    December 12, 2018 - Are national efforts to reduce drug name confusion paying off? December 12, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6. https://psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying Look-alike and sound-alike medications present a recurring threat to patie…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47989/psn-pdf
    August 14, 2019 - Ambulatory safety nets to reduce missed and delayed diagnoses of cancer. August 14, 2019 Emani S, Sequist TD, Lacson R, et al. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer. Jt Comm J Qual Patient Saf. 2019;45(8):552-557. doi:10.1016/j.jcjq.2019.05.010. https://psnet.ahrq.gov/issue/ambula…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47987/psn-pdf
    May 08, 2019 - Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. May 8, 2019 Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45098/psn-pdf
    May 04, 2016 - Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. May 4, 2016 The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016. https://psnet.ahrq.gov/issue/reducing…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867702/psn-pdf
    September 01, 2021 - Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. September 1, 2021 Agency for Healthcare Research and Quality. Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. September 2021. https://psnet.ahrq.gov/issue/toolkit-reduce-cauti-and-other-hais-long-term-care-facilities Cathete…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866846/psn-pdf
    September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50852/psn-pdf
    January 29, 2020 - Failure mode and effects analysis to reduce risk of heparin use. January 29, 2020 Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229. https://psnet.ahrq.gov/issue/failure-mode-and-effect…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36348/psn-pdf
    March 09, 2009 - Reducing medical error in the Military Health System: how can team training help? March 9, 2009 Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review. 2006;16(3). doi:10.1016/j.hrmr.2006.05.006. https://psnet.ahrq.g…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38569/psn-pdf
    May 20, 2009 - Reducing health care hazards: lessons from the Commercial Aviation Safety Team. May 20, 2009 Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hlthaff.28.3.w479. https://psnet.ahrq.gov/is…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866317/psn-pdf
    July 17, 2024 - BONE break: a hot debrief tool to reduce second victim syndrome for nurses. July 17, 2024 Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005. https://psnet.ahrq.gov/issue/bone…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73464/psn-pdf
    July 07, 2021 - Errors in breast imaging: how to reduce errors and promote a safety environment. July 7, 2021 Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118. https://psnet.ahrq.gov/issue/errors-breast-im…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47216/psn-pdf
    July 11, 2018 - Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed. July 11, 2018 Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380. https://psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-effort…

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