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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44869/psn-pdf
    November 18, 2016 - Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. November 18, 2016 Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47619/psn-pdf
    April 08, 2019 - A decade of health information technology usability challenges and the path forward. April 8, 2019 Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the Path Forward. JAMA. 2019;321(8):743-744. doi:10.1001/jama.2019.0161. https://psnet.ahrq.gov/issue/decade-health-in…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47574/psn-pdf
    November 21, 2018 - The architecture of safety: an emerging priority for improving patient safety. November 21, 2018 Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643. https://psnet.ahrq.gov/issue/…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44067/psn-pdf
    June 02, 2015 - Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals. June 2, 2015 Singer SJ, Jiang W, Huang LC, et al. Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals. Med Care Res Rev. 2015;72(3):298-323. doi:10.1177/1077558715577479. h…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46314/psn-pdf
    November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use. July 9, 2019 Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, and University of Chicago. https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use Improving antibiotic use is a st…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72672/psn-pdf
    January 27, 2021 - Use of simulation to measure the effects of just-in-time information to prevent nursing medication errors: a randomized controlled study. January 27, 2021 Berg TA, Hebert SH, Chyka D, et al. Use of Simulation to Measure the Effects of Just-in-Time Information to Prevent Nursing Medication Errors. Simul Healthc. 20…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45571/psn-pdf
    January 18, 2017 - How communication among members of the health care team affects maternal morbidity and mortality. January 18, 2017 Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884. doi:10.1016/j.jogn.2016.03…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43039/psn-pdf
    August 24, 2016 - How Doctors Think. August 24, 2016 Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030. https://psnet.ahrq.gov/issue/how-doctors-think In this book, the author presents several stories that illustrate the forces that shape physician decision- making and may lead to diagnostic mistakes. Borrowing from …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47664/psn-pdf
    April 03, 2019 - Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. April 3, 2019 Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Qual Saf. 2019;28(4):276-283…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855001/psn-pdf
    November 01, 2023 - Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. November 1, 2023 Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023. https://psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and- leaders Patient saf…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44490/psn-pdf
    September 16, 2015 - Implementation of a custom alert to prevent medication- timing errors associated with computerized prescriber order entry. September 16, 2015 Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry. Am J Heal…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837152/psn-pdf
    May 18, 2022 - AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report. May 18, 2022 Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019. https://psnet.ahrq.gov/issue/ahrq-safety-program-intensive-care-units-preventing-…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45745/psn-pdf
    August 02, 2017 - Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data. August 2, 2017 Abel GA, Mendonca SC, McPhail S, et al. Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data. Br J Gen Pract. 2017;67(65…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48034/psn-pdf
    May 22, 2019 - Chasing zero harm in radiation oncology: using pre- treatment peer review. May 22, 2019 Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre- treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302. https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854255/psn-pdf
    October 04, 2023 - Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. October 4, 2023 McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854826/psn-pdf
    October 25, 2023 - Observing sources of system resilience using in situ alarm simulations. October 25, 2023 McLoone M, McNamara M, Jennings MA, et al. Observing sources of system resilience using in situ alarm simulations. J Hosp Med. 2023;18(11):994-998. doi:10.1002/jhm.13217. https://psnet.ahrq.gov/issue/observing-sources-system-r…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46129/psn-pdf
    September 28, 2017 - Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. September 28, 2017 Quinn GR, Ranum D, Song E, et al. Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data. Jt Comm J Qual Patient Saf. 2017;43…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47713/psn-pdf
    June 14, 2019 - Medication appropriateness in vulnerable older adults: healthy skepticism of appropriate polypharmacy. June 14, 2019 Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. doi:10.1111/jgs.15798. https://psne…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72832/psn-pdf
    March 10, 2021 - Communication and Transparency as a Means to Strengthening Workplace Culture During COVID-19. March 10, 2021 Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021. doi:10.31478/202103a. https:/…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60213/psn-pdf
    April 08, 2020 - FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. April 8, 2020 FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. MedWatch Safety Alert. Silv…

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