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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43491/psn-pdf
    January 01, 2015 - The systems approach to medicine: controversy and misconceptions. December 9, 2014 Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ Qual Saf. 2015;24(1):7-9. doi:10.1136/bmjqs-2014-003106. https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconcept…
  3. www.ahrq.gov/topics/medicaid.html
    Topic: Medicaid Medicaid is state-based government health insurance that helps many low-income people in the United States to pay their medical bills. Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Me…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44436/psn-pdf
    October 30, 2017 - Overreaction. October 30, 2017 Shell ER. Overreaction. Scientific American. 2015;313(5):28-9. https://psnet.ahrq.gov/issue/overreaction Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to dete…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39465/psn-pdf
    May 08, 2018 - Latest heparin fatality speaks loudly—what have you done to stop the bleeding? May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3. https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding Detailing a recent lethal overdose of heparin, this …
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-d.pdf
    June 02, 2025 - Appendix D. Poster on Indications for Urinary Catheters AHRQ Safety Program for Reducing CAUTI in Hospitals Appendix D. Poster on Indications for Urinary Catheters In lower right, use Adobe Acrobat Pro to insert contact information for your institution. Does your patient really nee…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73431/psn-pdf
    June 23, 2021 - Drive to Deprescribe. June 23, 2021 The Society for Post-Acute and Long-Term Care Medicine. https://psnet.ahrq.gov/issue/drive-deprescribe Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning net…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37749/psn-pdf
    July 16, 2018 - Practice advisory for the prevention and management of operating room fires.  July 16, 2018 Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2. doi:10.1097/01.anes.0000299343.87119.a9. htt…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39766/psn-pdf
    August 18, 2010 - Paediatric dosing errors before and after electronic prescribing. August 18, 2010 Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068. https://psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-elec…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41972/psn-pdf
    January 23, 2013 - Impact of a pharmacotherapy alerting system on medication errors. January 23, 2013 Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors. American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126. https://psnet.ahrq.gov/issue/impact-pharmacothe…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42753/psn-pdf
    November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36431/psn-pdf
    March 28, 2011 - Using the internet to deliver education on drug safety. March 28, 2011 Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health Care. 2006;15(5):329-33. https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety The project team implemented a web-…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50727/psn-pdf
    December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been a factor? December 11, 2019 Glicksman E. Washington Post. November 17, 2019. https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor Unconscious assumptions and biases are known contributors to poor decision-making. This news st…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37653/psn-pdf
    May 14, 2008 - Getting boards on board: engaging governing boards in quality and safety.  May 14, 2008 Conway JB. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual Saf. 2008;34(4):214-220. https://psnet.ahrq.gov/issue/getting-boards-board-engaging-governing-boards-quality-and-safety This a…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42344/psn-pdf
    September 24, 2016 - Strategies for preventing distractions and interruptions in the OR. September 24, 2016 Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707. doi:10.1016/j.aorn.2013.01.018. https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or Dist…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40696/psn-pdf
    December 01, 2011 - Rapid response systems: a prospective study of response times. December 1, 2011 Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013. https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43318/psn-pdf
    July 02, 2014 - Sign up to Safety. July 2, 2014 National Health Service. https://psnet.ahrq.gov/issue/sign-safety Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service facilities.…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37704/psn-pdf
    April 23, 2008 - Decreasing paediatric prescribing errors in a district general hospital. April 23, 2008 Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital. Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212. https://psnet.ahrq.gov/issue/decreasing-paediatric-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36039/psn-pdf
    March 02, 2011 - The effects of on-duty napping on intern sleep time and fatigue. March 2, 2011 Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med. 2006;144(11):792-8. https://psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue The investigators …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46466/psn-pdf
    July 11, 2018 - Distinct newborn identification requirement. July 11, 2018 R3 Report. June 25, 2018;7:1-2. https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement Neonatal patients are at risk for misidentification due to communication challenges and lack of distinguishable features. This report highlights new Jo…