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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47354/psn-pdf
    November 21, 2018 - Improving Diagnosis in Medicine Change Package. November 21, 2018 Chicago, IL: Health Research & Educational Trust; 2018. https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47621/psn-pdf
    May 11, 2019 - 2018 update on pediatric medical overuse: a review. May 11, 2019 Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550. https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review Overuse of …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836788/psn-pdf
    March 23, 2022 - A widow’s mission to change NC dental sedation rules. March 23, 2022 Blythe A. NC Health News. March 10, 2022 https://psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60563/psn-pdf
    June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44880/psn-pdf
    September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42197/psn-pdf
    September 24, 2016 - Interruptions during nurses' work: a state-of-the-science review. September 24, 2016 Hopkinson SG, Jennings BM. Interruptions during nurses' work: A state-of-the-science review. Res Nurs Health. 2013;36(1):38-53. doi:10.1002/nur.21515. https://psnet.ahrq.gov/issue/interruptions-during-nurses-work-state-science-rev…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43411/psn-pdf
    October 01, 2014 - Analysis of medication errors in simulated pediatric resuscitation by residents. October 1, 2014 Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by residents. West J Emerg Med. 2014;15(4):486-90. doi:10.5811/westjem.2014.2.17922. https://psnet.ahrq.gov/issue/analysis…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36976/psn-pdf
    June 15, 2011 - Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. June 15, 2011 Evans S, Smith B, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care. 2007;16(3):169-75. https://psnet.ahrq.gov/issue/evaluation…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44678/psn-pdf
    July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36387/psn-pdf
    July 14, 2010 - Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians. July 14, 2010 Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk Abbreviations Written by Physicians. J Patient Saf. 2008;2(3). doi:10.1097/0…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43748/psn-pdf
    December 03, 2014 - New enteral connectors: raising awareness. December 3, 2014 Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5). doi:10.1177/0884533614543330. https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness Redesigning tubing connectors according to new ISO standards has the potenti…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42160/psn-pdf
    April 03, 2013 - The perianesthesia nurse's role in the prevention of opioid-related sentinel events. April 3, 2013 Pasero C. The perianesthesia nurse's role in the prevention of opioid-related sentinel events. J Perianesth Nurs. 2013;28(1):31-7. doi:10.1016/j.jopan.2012.11.001. https://psnet.ahrq.gov/issue/perianesthesia-nurses-r…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41334/psn-pdf
    April 25, 2012 - Understanding the role of non-technical skills in patient safety. April 25, 2012 White N. Understanding the role of non-technical skills in patient safety. Nurs Stand. 2012;26(26):43-8. https://psnet.ahrq.gov/issue/understanding-role-non-technical-skills-patient-safety Examining a case study in which a patient die…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43151/psn-pdf
    April 30, 2014 - Open for Better Care. April 30, 2014 Health Quality & Safety Commission New Zealand. https://psnet.ahrq.gov/issue/open-better-care This Web site hosts tools and resources associated with a national campaign to augment patient care. The initiative aims to build collaborative programs across New Zealand to reduce fa…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60042/psn-pdf
    March 11, 2020 - At Walgreens, complaints of medication errors go missing. March 11, 2020 Gabler E. New York Times. February 23, 2020. https://psnet.ahrq.gov/issue/walgreens-complaints-medication-errors-go-missing Response to reported safety concerns is a primary indicator of an organizational commitment to reducing and lear…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837679/psn-pdf
    July 13, 2022 - Provider implicit bias: bringing awareness to clinical practice. July 13, 2022 Moss LD. Clinical Advisor. June 29, 2022. https://psnet.ahrq.gov/issue/provider-implicit-bias-bringing-awareness-clinical-practice Health disparities perpetuated by structural racism degrade patient safety. This article discusses the i…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43941/psn-pdf
    February 25, 2015 - How to make surgery safer. February 25, 2015 https://psnet.ahrq.gov/issue/how-make-surgery-safer This newspaper article reports on various ways hospitals are working to make surgical care safer and reduce readmissions due to surgical complications, including checklists, teamwork training courses for surgeons, preo…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45336/psn-pdf
    September 21, 2016 - Medical misdiagnoses put pressure on patients to stay engaged. September 21, 2016 Innes S. Arizona Daily Star. September 12, 2016. https://psnet.ahrq.gov/issue/medical-misdiagnoses-put-pressure-patients-stay-engaged Delayed diagnoses can have serious consequences. This news article reviews several examples of mis…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39626/psn-pdf
    June 23, 2010 - The Medication Manager: results of a medication at the bedside pilot in a pediatric teaching institution. June 23, 2010 Wagner D, Pasko D, Glenn D, et al. The Medication Manager. J Patient Saf. 2010;6(2). doi:10.1097/pts.0b013e3181cb43b4. https://psnet.ahrq.gov/issue/medication-manager-results-medication-bedside-p…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867699/psn-pdf
    June 01, 2023 - Toolkit for Improving Surgical Care and Recovery. June 1, 2023 Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June 2023. https://psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery Improving patient experience fosters better communication, trust, and col…

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