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8181. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73077/psn-pdf
      March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…

8182. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46020/psn-pdf
      July 21, 2017 - Towards high-reliability organising in healthcare: a strategy for building organisational capacity. July 21, 2017 Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for building organisational capacity. BMJ Qual Saf. 2017;26(8):663-670. doi:10.1136/bmjqs-2016-00624…

8183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42539/psn-pdf
      September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…

8184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43565/psn-pdf
      March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects analysis (FMEA) h…

8185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44378/psn-pdf
      August 05, 2015 - Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. August 5, 2015 Harris Y, Hu DJ, Lee C, et al. Advancing Medication Safety: Establishing a National Action Plan for Adverse Drug Event Prevention. Jt Comm J Qual Patient Saf. 2015;41(8):351-60. https://psnet.ahrq.gov…

8186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837040/psn-pdf
      May 04, 2022 - Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication. May 4, 2022 Silver Spring, MD: US Food and Drug Administration; April 5, 2022. https://psnet.ahrq.gov/issue/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety- communication The challenge of medical device steriliza…

8187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40598/psn-pdf
      August 10, 2011 - An inpatient fall prevention initiative in a tertiary care hospital. August 10, 2011 Weinberg J, Proske D, Szerszen A, et al. An inpatient fall prevention initiative in a tertiary care hospital. Jt Comm J Qual Patient Saf. 2011;37(7):317-325. https://psnet.ahrq.gov/issue/inpatient-fall-prevention-initiative-tertia…

8188. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45782/psn-pdf
      January 18, 2017 - Standardization of inpatient handoff communication. January 18, 2017 Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681. https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication Handoffs at shift changes are vulnerable to…

8189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39731/psn-pdf
      August 04, 2010 - Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. August 4, 2010 Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009. https://ps…

8190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41546/psn-pdf
      December 29, 2014 - Using a logic model to design and evaluate quality and patient safety improvement programs. December 29, 2014 Goeschel CA, Weiss WM, Pronovost P. Using a logic model to design and evaluate quality and patient safety improvement programs. Int J Qual Health Care. 2012;24(4):330-7. doi:10.1093/intqhc/mzs029. https://…

8191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45094/psn-pdf
      May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. May 4, 2016 Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16- 328. https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care This analysis found that s…

8192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48028/psn-pdf
      August 28, 2019 - Error Reduction and Prevention in Surgical Pathology, Second Edition. August 28, 2019 Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636. https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition Surgical specimen and laboratory process proble…

8193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838137/psn-pdf
      September 21, 2022 - How insight contributes to diagnostic excellence. September 21, 2022 Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311- 315. doi:10.1515/dx-2022-0007. https://psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence Improving diagnostic reasoning skil…

8194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74724/psn-pdf
      February 02, 2022 - Using smart IV infusion pumps outside of patient rooms. February 2, 2022 Messing EG, Abraham RS, Quinn NJ, et al. Using smart IV infusion pumps outside of patient rooms. Am J Nurs. 2022;122(2). doi:10.1097/01.naj.0000819772.45006.5d. https://psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms …

8195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45035/psn-pdf
      January 23, 2017 - Premature closure? Not so fast. January 23, 2017 Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016- 005267. https://psnet.ahrq.gov/issue/premature-closure-not-so-fast Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…

8196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44712/psn-pdf
      December 09, 2015 - The effect of contact precautions on frequency of hospital adverse events. December 9, 2015 Croft LD, Liquori M, Ladd J, et al. The Effect of Contact Precautions on Frequency of Hospital Adverse Events. Infect Control Hosp Epidemiol. 2015;36(11):1268-74. doi:10.1017/ice.2015.192. https://psnet.ahrq.gov/issue/effec…

8197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837695/psn-pdf
      July 20, 2022 - Narrowing the mindware gap in medicine. July 20, 2022 Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183. doi:10.1515/dx-2020-0128. https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…

8198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46501/psn-pdf
      March 20, 2018 - Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. March 20, 2018 Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104. https://psnet.ahrq.gov/issue/blind…

8199. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47681/psn-pdf
      January 30, 2019 - Infection prevention in the operating room anesthesia work area. January 30, 2019 Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303. https://psnet.ahrq.gov/issue/infection-prevention-operat…

8200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41717/psn-pdf
      September 01, 2016 - A clinical data warehouse-based process for refining medication orders alerts. September 1, 2016 Boussadi A, Caruba T, Zapletal E, et al. A clinical data warehouse-based process for refining medication orders alerts. J Am Med Inform Assoc. 2012;19(5):782-5. doi:10.1136/amiajnl-2012-000850. https://psnet.ahrq.gov/i…