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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43664/psn-pdf
    September 01, 2016 - Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. September 1, 2016 Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive ob…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46851/psn-pdf
    January 23, 2019 - To care is human—collectively confronting the clinician- burnout crisis. January 23, 2019 Dzau VJ, Kirch DG, Nasca TJ. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis. New Engl J Med. 2018;378(4):312-314. doi:10.1056/nejmp1715127. https://psnet.ahrq.gov/issue/care-human-collectively-confro…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45116/psn-pdf
    February 15, 2017 - Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies. February 15, 2017 de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events inconsistently improved by the World Health Organization surgical s…
  4. 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…
  5. 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…
  6. 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 …
  7. 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…
  8. 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…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852808/psn-pdf
    August 30, 2023 - Ginger capsules (250 mg four times daily) may reduce nausea but have no apparent benefit in reducing
  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - – Ginger capsules (250 mg four times daily) may reduce nausea but have no apparent benefit in reducing
  12. psnet.ahrq.gov/web-mm/spinal-epidural-abscess
    November 13, 2019 - The National Academy of Science, Engineering, and Medicine made recommendations about reducing diagnostic
  13. psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
    October 19, 2022 - June 7, 2017 A dynamic risk management approach for reducing harm from invasive bedside
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49685/psn-pdf
    May 01, 2013 - Polypharmacy May 1, 2013 Guglielmo JB. Polypharmacy. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/polypharmacy The Case A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency. His case manager visits him weekly regarding medication adherence, which include…
  15. psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
    May 01, 2013 - research that all of us face is not becoming too wedded to any particular solution for improving quality, reducing … harm, or reducing health care costs.
  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
    January 01, 2021 - Conversions Intelligently 37 Utilizing OME (1) • To switch from one opioid to another with the goal of reducing … equianalgesic dose) Utilizing OME: Equianalgesic Calculations (6) Step 3: Account for cross-tolerance by reducing
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41175/psn-pdf
    December 31, 2014 - Design and implementation of an automated email notification system for results of tests pending at discharge. December 31, 2014 Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification system for results of tests pending at discharge. J Am Med Inform Assoc. 2012;19(4):52…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48007/psn-pdf
    May 21, 2019 - Structured override reasons for drug–drug interaction alerts in electronic health records. May 21, 2019 Wright A, McEvoy D, Aaron S, et al. Structured override reasons for drug-drug interaction alerts in electronic health records. J Am Med Info Asso. 2019;26(10):934-942. doi:10.1093/jamia/ocz033. https://psnet.ahr…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42966/psn-pdf
    November 21, 2018 - The next organizational challenge: finding and addressing diagnostic error. November 21, 2018 Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10. https://psnet.ahrq.gov/issue/next-organizational-challe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45863/psn-pdf
    August 28, 2017 - Large-scale implementation of the I-PASS handover system at an academic medical centre. August 28, 2017 Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjqs-2016-006195. https://psnet.ahr…

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