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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45625/psn-pdf
    November 01, 2017 - Building comprehensive strategies for obstetric safety: simulation drills and communication. November 1, 2017 Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication. Anesth Analg. 2016;123(5):1181-1190. https://psnet.ahrq.gov/is…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47270/psn-pdf
    August 08, 2018 - A method to identify pediatric high-risk diagnoses missed in the emergency department. August 8, 2018 Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018-0005. https://psnet.ahrq.gov/iss…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38070/psn-pdf
    March 10, 2011 - Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. March 10, 2011 Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43326/psn-pdf
    August 13, 2014 - Identifying high-risk medication: a systematic literature review. August 13, 2014 Saedder EA, Brock B, Nielsen LP, et al. Identifying high-risk medication: a systematic literature review. Eur J Clin Pharmacol. 2014;70(6):637-45. doi:10.1007/s00228-014-1668-z. https://psnet.ahrq.gov/issue/identifying-high-risk-medi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47237/psn-pdf
    January 01, 2020 - First-year analysis of the Operating Room Black Box study. July 25, 2018 Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg. 2020;271(1):122-127. doi:10.1097/SLA.0000000000002863. https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study An…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46390/psn-pdf
    October 29, 2017 - Using data to enhance performance and improve quality and safety in surgery. October 29, 2017 Goldenberg MG, Jung JJ, Grantcharov T. Using Data to Enhance Performance and Improve Quality and Safety in Surgery. JAMA Surg. 2017;152(10):972-973. doi:10.1001/jamasurg.2017.2888. https://psnet.ahrq.gov/issue/using-data-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46383/psn-pdf
    September 20, 2017 - Prescription Drug Monitoring Programs: Evolution and Evidence. September 20, 2017 Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017. https://psnet.ahrq.gov/issue/prescription-drug-monitoring-programs-evolution-and-evidence Health care has been exploring a variety of strategies to mitigate the opioid ep…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34868/psn-pdf
    February 03, 2011 - Role of computerized physician order entry systems in facilitating medication errors. February 3, 2011 Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-203. https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46149/psn-pdf
    June 28, 2017 - Clinical outcomes associated with medication regimen complexity in older people: a systematic review. June 28, 2017 Wimmer BC, Cross AJ, Jokanovic N, et al. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2016;65(4):747-753. doi:10.1111/jgs.14…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36529/psn-pdf
    August 09, 2011 - 5 Million Lives Campaign. August 9, 2011 Institute for Healthcare Improvement; IHI https://psnet.ahrq.gov/issue/5-million-lives-campaign The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than 3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840167/psn-pdf
    November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation. November 16, 2022 Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759. https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43114/psn-pdf
    April 09, 2014 - The ethics of empowering patients as partners in healthcare-associated infection prevention. April 9, 2014 Sharp D, Palmore T, Grady C. The ethics of empowering patients as partners in healthcare-associated infection prevention. Infect Control Hosp Epidemiol. 2014;35(3):307-9. doi:10.1086/675288. https://psnet.ahr…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43692/psn-pdf
    April 22, 2015 - Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. April 22, 2015 Westaby S, De Silva R, Petrou M, et al. Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services. Eur J Cardiothorac Surg. 2015;47(2):341-5. doi:10.1093/ejcts/ezu380. h…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843521/psn-pdf
    February 01, 2023 - How providers can optimize effective and safe scribe use: a qualitative study. February 1, 2023 Corby S, Ash JS, Florig ST, et al. How providers can optimize effective and safe scribe use: a qualitative study. J Gen Intern Med. 2023;38(9):2052-2058. doi:10.1007/s11606-022-07942-2. https://psnet.ahrq.gov/issue/how-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43616/psn-pdf
    October 29, 2014 - Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program. October 29, 2014 Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1- S141. https://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lesson…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47503/psn-pdf
    October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs. October 24, 2018 Peeples L. Pharmacy Practice News. October 10, 2018. https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs Structured handoffs can reduce communication problems that contribute to medical error. This magazine article re…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46100/psn-pdf
    July 11, 2017 - The tension between promoting mobility and preventing falls in the hospital. July 11, 2017 Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840. https://psnet.ahrq.gov/issue/tension-be…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72750/psn-pdf
    February 17, 2021 - Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis. February 17, 2021 Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-140. doi:10.1097/pts.00000000000…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44183/psn-pdf
    November 03, 2015 - The absence of a drug–disease interaction alert leads to a child's death. November 3, 2015 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4. https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death The disabling of alerts due to alarm fatigue can hinder the abilit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73253/psn-pdf
    May 12, 2021 - Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021 ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5. https://psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease- 2019-c…

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