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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38992/psn-pdf
    April 16, 2018 - Safe patient outcomes occur with timely, standardized communication of critical values. April 16, 2018 https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical- values This article reports on failures surrounding critical test results and describes mechanisms to standardi…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39255/psn-pdf
    February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37654/psn-pdf
    September 24, 2010 - The road to zero preventable birth injuries. September 24, 2010 Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205. https://psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries This article reports how a perinatal safety team, which …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41636/psn-pdf
    August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff. August 29, 2012 Eisler P. USA Today. August 16, 2012. https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acq…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41562/psn-pdf
    August 01, 2012 - The Final Check: Say it Out Loud. August 1, 2012 https://psnet.ahrq.gov/issue/final-check-say-it-out-loud This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts. https://psnet.ahrq.gov/issue/final-check-say-it-out-loud https://psnet.ahrq.gov/web-mm/ri…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40553/psn-pdf
    June 22, 2011 - Applying the Universal Protocol to improve patient safety in radiology services. June 22, 2011 PA-PSRS Patient Saf Advis. June 2011;8:63-69. https://psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services Exploring causes of wrong-site, wrong patient, and wrong procedure errors i…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50584/psn-pdf
    October 23, 2019 - Unprotected: broken promises in Georgia’s senior care industry. October 23, 2019 Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019. https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry Assisted living facilities have challenges that reduce the quality and saf…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37743/psn-pdf
    June 06, 2008 - Incidence and prevention of iatrogenic urethral injuries. June 6, 2008 Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108. https://psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-ureth…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41447/psn-pdf
    May 30, 2012 - Massachusetts hospitals launch patient apology program. May 30, 2012 Gallegos A. https://psnet.ahrq.gov/issue/massachusetts-hospitals-launch-patient-apology-program This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to reduce liability lawsuits. https://psnet.ahrq…
  10. psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - Mixing fewer drugs together or using a local anesthetic alone for spinal injection reduces the chance
  11. psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016  Also Read an Essay Citation Text: In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…
  12. psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
    October 13, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization National Institute for Occupational Safety and Health (…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39793/psn-pdf
    August 25, 2010 - Infection Control in the Intensive Care Unit. August 25, 2010 Crit Care Med. 2010;38:S265-S404.   https://psnet.ahrq.gov/issue/infection-control-intensive-care-unit Articles in this special issue describe strategies to reduce infections in the intensive care unit, including human factors design, guideline use…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41831/psn-pdf
    December 31, 2012 - The economics of health care quality and medical errors. December 31, 2012 Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health Care Finance. 2012;39(1):39-50. https://psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors Discussing the financia…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36077/psn-pdf
    July 05, 2006 - Perinatal patient safety from the perspective of nurse executives: a round table discussion. July 5, 2006 Thorman KE; Capitulo KL; Dubow J; Hanold K; Noonan M; Wehmeyer J. https://psnet.ahrq.gov/issue/perinatal-patient-safety-perspective-nurse-executives-round-table-discussion The authors summarize a discussion be…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40406/psn-pdf
    February 13, 2018 - Critical conversations: a call for a nonprocedural "time out." February 13, 2018 Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853. https://psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out This…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34621/psn-pdf
    September 27, 2017 - Human Factors and Medical Devices. September 27, 2017 Center for Devices and Radiological Health, US Food and Drug Administration. https://psnet.ahrq.gov/issue/human-factors-and-medical-devices Human factors engineering (HFE) helps improve human performance and reduce the risks associated with use error. The U.S. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41508/psn-pdf
    July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. July 11, 2012 Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0. https://psnet.ahrq.gov/issue/complications-surgery-root-cause…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36146/psn-pdf
    February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38475/psn-pdf
    March 10, 2011 - Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency. March 10, 2011 Sellier E, Colombet I, Sabatier B, et al. Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency. J Am Med Inform Assoc. 2009;16(2):203-10. doi:10.1197/jamia.M2805. https://psnet.ahrq.gov/…

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