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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44782/psn-pdf
    January 13, 2016 - The Swiss cheese model of adverse event occurrence—closing the holes. January 13, 2016 Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003. https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45019/psn-pdf
    April 27, 2016 - Effectiveness of surgical safety checklists in improving patient safety. April 27, 2016 Ragusa PS, Bitterman A, Auerbach B, et al. Effectiveness of Surgical Safety Checklists in Improving Patient Safety. Orthopedics. 2016;39(2):e307-10. doi:10.3928/01477447-20160301-02. https://psnet.ahrq.gov/issue/effectiveness-s…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45987/psn-pdf
    April 26, 2017 - Using simulation to prepare nursing staff for the move to a new building. April 26, 2017 Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329. https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42961/psn-pdf
    February 19, 2014 - Healthcare-associated infections: a national patient safety problem and the coordinated response. February 19, 2014 Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581. https://psne…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41633/psn-pdf
    January 01, 2013 - Determinants of success of quality improvement collaboratives: what does the literature show? December 31, 2012 Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651. https…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41911/psn-pdf
    December 12, 2012 - Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. December 12, 2012 Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50575/psn-pdf
    October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift handover communication. October 23, 2019 Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831. https://psnet.ahrq.gov/issue/dynam…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46742/psn-pdf
    March 14, 2018 - Evidence-based guidelines for fatigue risk management in emergency medical services. March 14, 2018 Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101. doi:10.1080/10903127.2017.1376137. https…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44843/psn-pdf
    September 06, 2016 - Addressing the Global Shortages of Medicines, and the Safety and Accessibility of Children's Medication. September 6, 2016 Geneva, Switzerland: World Health Organization; 2015. https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens- medication Drug shortages have…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35971/psn-pdf
    May 27, 2011 - Effectiveness of computerized provider order entry with dose range checking on prescribing errors. May 27, 2011 Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44014/psn-pdf
    March 20, 2019 - Patient Centered Medical Home Resource Center: Quality and Safety. March 20, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43888/psn-pdf
    August 02, 2015 - Diagnostic performance by medical students working individually or in teams. August 2, 2015 Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770. https://psnet.ahrq.gov/issue/diagnostic-performance…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48001/psn-pdf
    May 22, 2019 - Medicines safety in anaesthetic practice. May 22, 2019 Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001. https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice Human factors affect medication delivery in the operating …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74118/psn-pdf
    January 01, 2022 - From HRO to HERO: making health equity a core system capability. November 24, 2021 Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability. Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020. https://psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-syst…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37469/psn-pdf
    January 16, 2008 - Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led approach. January 16, 2008 Weiner BK, Venarske J, Yu M, et al. Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led approach. Spine (Phila Pa 1976).…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38068/psn-pdf
    March 10, 2011 - The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. March 10, 2011 Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585-600. …
  17. www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/lets-talk-about-it-discussion-guides/lets-talk-about-it-medicines-help-prevent-breast-cancer-discussion-guide-healthcare-providers-and-patients
    June 06, 2025 - Let's Talk About It: Medicines to Help Prevent Breast Cancer Discussion Guide for Healthcare Providers and Patients Share to Facebook Share to X Share to WhatsApp Share to Email Print Download English PDF Download Spanish PDF   Let's T…
  18. www.ahrq.gov/patient-safety/about/national-steering-committee.html
    June 01, 2021 - National Steering Committee for Patient Safety YouTube embedded video: https://www.youtube-nocookie.com/embed/QUxyRDRTyLA AHRQ is co-leading the National Steering Committee for Patient Safety, which includes members from  two dozen organizations that are joining together to create a national action plan to ac…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867449/psn-pdf
    March 13, 2025 - Medication Related Harm. March 13, 2025 Medication Related Harm. Health Services Safety Investigations Body. 2024-2025 https://psnet.ahrq.gov/issue/medication-related-harm Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024…
  20. www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
    January 01, 2014 - Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic) REDUCTION IN HACs REDUCTION IN HACs 17%17% LIVES SAVEDLIVES SAVED 87,00087,000 $$$ IN COSTS AVERTEDIN COSTS AVERTED $19.8 BILLION $19.8 BILLION INSTANCES OF HACs AVOIDED INSTANCES OF HACs AVOIDED 2.1 MILLION 2.1 MILLION From 2010–2014, 1…