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7641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45386/psn-pdf
      November 23, 2016 - Balancing doctor egos and errors. November 23, 2016 Sweeney JF. Medical Economics. November 10, 2016. https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors Disclosure and candor with patients after a medical error has gained support from organizations, clinicians, and patients. This magazine article discus…

7642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46799/psn-pdf
      March 20, 2018 - Seen through the patients' eyes: surgical safety and checklists. March 20, 2018 Bergs J, Lambrechts F, Desmedt M, et al. Seen through the patients' eyes: surgical safety and checklists. Int J Qual Health Care. 2018;30(2):118-123. doi:10.1093/intqhc/mzx180. https://psnet.ahrq.gov/issue/seen-through-patients-eyes-su…

7643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35644/psn-pdf
      January 18, 2006 - Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. January 18, 2006 Tsai JJ, Yeun JY, Kumar VA, et al. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005;46(5):82…

7644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43996/psn-pdf
      November 10, 2018 - When doing wrong feels so right: normalization of deviance. November 10, 2018 Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157. https://psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance This…

7645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42102/psn-pdf
      April 03, 2013 - Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. April 3, 2013 Patterson ES, Zhang J, Abbott P, et al. Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. Jt Comm J Qual Patient Saf. 2013;39(3):129-135. https://psnet.a…

7646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42955/psn-pdf
      May 11, 2016 - National Patient Safety Alerting System. May 11, 2016 National Health Service England https://psnet.ahrq.gov/issue/national-patient-safety-alerting-system In response to the Francis report, this three-stage reporting system was launched to help National Health Service organizations learn from incidents and incorpo…

7647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48072/psn-pdf
      June 19, 2019 - Independent double checks: worth the effort if used judiciously and properly. June 19, 2019 ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7. https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly Independent double checks can reduce risk of human …

7648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74143/psn-pdf
      December 01, 2021 - Confronting Racism in Health Care: Moving from Proclamations to New Practices. December 1, 2021 Hostetter M, Klein S. New York, NY: Commonwealth Fund;  October 18, 2021 https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices Structural racism affects the safety and equit…

7649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44495/psn-pdf
      September 30, 2015 - Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. September 30, 2015 Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.1136/bmjqs-2014- 003921. htt…

7650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42925/psn-pdf
      February 05, 2014 - Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections. February 5, 2014 Hamilton DK, Stichler JF, eds. HERD. 2013;7(suppl):1-154. https://psnet.ahrq.gov/issue/understanding-role-facility-design-acquisition-and-prevention-healthcare- associated Articles in…

7651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836999/psn-pdf
      April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs. April 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; April 2022. https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this cu…

7652. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41296/psn-pdf
      April 11, 2012 - I-PASS, a mnemonic to standardize verbal handoffs. April 11, 2012 Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-4. doi:10.1542/peds.2011-2966. https://psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs Poor communication at…

7653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39993/psn-pdf
      July 03, 2014 - The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. July 3, 2014 Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and patient safety efforts in infection prev…

7654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47781/psn-pdf
      February 27, 2019 - Medicine Safety: Take Care. February 27, 2019 Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019. https://psnet.ahrq.gov/issue/medicine-safety-take-care Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care ad…

7655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47485/psn-pdf
      January 09, 2019 - System-related and cognitive errors in laboratory medicine. January 9, 2019 Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191- 196. doi:10.1515/dx-2018-0085. https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine Problems managing …

7656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44488/psn-pdf
      September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare- Associated Infections (HAIs). September 16, 2015 Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15- EHC020-EF. https://p…

7657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44717/psn-pdf
      February 10, 2016 - Trends and patterns in reporting of patient safety situations in transplantation. February 10, 2016 Stewart DE, Tlusty SM, Taylor KH, et al. Trends and Patterns in Reporting of Patient Safety Situations in Transplantation. Am J Transplant. 2015;15(12):3123-33. doi:10.1111/ajt.13528. https://psnet.ahrq.gov/issue/tr…

7658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837979/psn-pdf
      August 31, 2022 - Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional). August 31, 2022 National Institutes of Health.  August 11, 2022. RFA-HD-23-035. https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional Maternity care is increasingly being recognized as …

7659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863223/psn-pdf
      February 28, 2024 - Prioritizing Patient Safety Through Quality Measurement. February 28, 2024 Centers for Medicare & Medicaid Services, March 6 and 21, 2024.  https://psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement Quality measurement intersects with patient safety and care improvement efforts to…

7660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44846/psn-pdf
      August 31, 2016 - Making health care safer: protect patients from antibiotic resistance. August 31, 2016 CDC; Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance Health care–associated infections (HAI) are a worldwide patient safety problem. This a…