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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39231/psn-pdf
    January 13, 2010 - The Checklist Manifesto: How to Get Things Right. January 13, 2010 Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748. https://psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through his art…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37417/psn-pdf
    March 28, 2012 - Medication use leading to emergency department visits for adverse drug events in older adults. March 28, 2012 Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765. https://psnet.ahrq.gov/issue/med…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46098/psn-pdf
    July 24, 2017 - Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study. July 24, 2017 Dykes PC, Rozenblum R, Dalal A, et al. Prospective Evaluation of a Multifaceted Intervention to Improve …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73252/psn-pdf
    January 01, 2022 - Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. May 12, 2021 Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37768/psn-pdf
    April 27, 2010 - The wisdom and justice of not paying for "preventable complications." April 27, 2010 Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197. https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45402/psn-pdf
    November 01, 2017 - Potentially preventable 30-day hospital readmissions at a children's hospital. November 1, 2017 Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182. https://psnet.ahrq.gov/issue/potentially-preventabl…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46616/psn-pdf
    July 02, 2019 - Medication-related clinical decision support alert overrides in inpatients. July 2, 2019 Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115. https://psnet.ahrq.gov/issue/medication-rel…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40619/psn-pdf
    October 06, 2016 - Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. October 6, 2016 Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542/peds.2010-3772. https://psnet.a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60552/psn-pdf
    June 03, 2020 - Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. June 3, 2020 Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthc…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43486/psn-pdf
    September 01, 2016 - Indication alerts intercept drug name confusion errors during computerized entry of medication orders. September 1, 2016 Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during computerized entry of medication orders. PLoS One. 2014;9(7):e101977. doi:10.1371/journal.pone…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45425/psn-pdf
    December 22, 2018 - Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records. December 22, 2018 Kirkendall ES, Kouril M, Dexheimer JW, et al. Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing ale…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845278/psn-pdf
    March 01, 2023 - Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control. March 1, 2023 Magnan EM, Tancredi DJ, Xing G, et al. Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control. JAMA Netw Open. 2023…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46856/psn-pdf
    June 20, 2018 - Visual acuity, literacy, and unintentional misuse of nonprescription medications. June 20, 2018 Mullen RJ, Curtis LM, O'Conor R, et al. Visual acuity, literacy, and unintentional misuse of nonprescription medications. Am J Health-Syst Pharm. 2018;75(9):e213-e220. doi:10.2146/ajhp170303. https://psnet.ahrq.gov/issu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39641/psn-pdf
    September 20, 2011 - Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. September 20, 2011 Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303(24):2479-85. doi:10.1…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44004/psn-pdf
    September 01, 2016 - Impact of computerized physician order entry alerts on prescribing in older patients. September 1, 2016 Lester PE, Rios-Rojas L, Islam S, et al. Impact of computerized physician order entry alerts on prescribing in older patients. Drugs Aging. 2015;32(3):227-33. doi:10.1007/s40266-015-0244-2. https://psnet.ahrq.go…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38536/psn-pdf
    February 03, 2011 - Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality. February 3, 2011 Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13). doi:10.1001/jama.2009.423. https://psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-an…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40393/psn-pdf
    December 21, 2014 - Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. December 21, 2014 O'Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684. doi:10.1001/archinternmed.2011.128. http…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47735/psn-pdf
    June 24, 2019 - The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. June 24, 2019 Boston, MA: Betsy Lehman Center for Patient Safety; June 2019. https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead- way-patient-safety The Betsy L…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49445/psn-pdf
    May 01, 2004 - No Blood, Please May 1, 2004 Liang BA. No Blood, Please. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/no-blood-please The Case A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the emergency department (ED) via ambulance, where she was found to be suffering …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33592/psn-pdf
    December 15, 2024 - Adverse Events, Near Misses, and Errors December 15, 2024 Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current re…

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