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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50688/psn-pdf
    November 20, 2019 - Roles and role ambiguity in patient- and caregiver- performed outpatient parenteral antimicrobial therapy. November 20, 2019 Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837417/psn-pdf
    June 15, 2022 - A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system. June 15, 2022 Abdelmalak BB, Adhami T, Simmons W, et al. A blueprint for success: implementation of the Center for Medicare and Medicaid Serv…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47258/psn-pdf
    January 09, 2019 - The effect of cognitive load and task complexity on automation bias in electronic prescribing. January 9, 2019 Lyell D, Magrabi F, Coiera E. The Effect of Cognitive Load and Task Complexity on Automation Bias in Electronic Prescribing. Hum Factors. 2018;60(7):1008-1021. doi:10.1177/0018720818781224. https://psnet.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36433/psn-pdf
    February 10, 2011 - Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. February 10, 2011 Hunt DL, Haynes RB, Hanna SE, et al. Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes. JAMA. 2003;280(15):1339-1…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47453/psn-pdf
    May 20, 2019 - Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences. May 20, 2019 White AA, Sage WM, Osinska PH, et al. Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences. BMJ Qual Saf. 2019;28(6):468-475. doi:10.1136/bmjqs…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46456/psn-pdf
    February 28, 2018 - Drug calculation ability of qualified paramedics: a pilot study. February 28, 2018 Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006. https://psnet.ahrq.gov/issue/drug-calculation-ability-qualified-par…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35251/psn-pdf
    April 06, 2011 - Promoting health care safety through training high reliability teams. April 6, 2011 Wilson KA. Promoting health care safety through training high reliability teams. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010090. https://psnet.ahrq.gov/issue/promoting-health-care-safety-through-trainin…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74116/psn-pdf
    November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. November 24, 2021 Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN: 9781945365416. https://psnet.ahrq.gov/issue/ncicle-pathwa…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46447/psn-pdf
    September 27, 2017 - Creating highly reliable accountable care organizations. September 27, 2017 Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev. 2016;73(6):660-672. https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations High reliability is a goal throughout …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854255/psn-pdf
    October 04, 2023 - Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. October 4, 2023 McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44877/psn-pdf
    April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices. April 27, 2016 Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16- 158. https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and- pre…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44391/psn-pdf
    January 22, 2016 - Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. January 22, 2016 Marsteller JA, Wen M, Hsu Y-J, et al. Safety Culture in Cardiac Surgical Teams: Data From Five Programs and National Surgical Comparison. Ann Thorac Surg. 2015;100(6):2182-9. doi:10.1016/j.athoracsu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40984/psn-pdf
    September 01, 2016 - Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. September 1, 2016 Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts. J Am Med …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. January 5, 2017 Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3. https://psnet.ah…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41561/psn-pdf
    August 01, 2012 - Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. August 1, 2012 Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092. https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reporte…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45845/psn-pdf
    December 19, 2017 - You can't blame the wreck on the train. December 19, 2017 Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978. doi:10.1016/j.amjsurg.2016.11.046. https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train Insufficient supervision can limit resident education, which may increase risks to p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44406/psn-pdf
    December 04, 2016 - Drug manufacturers' delayed disclosure of serious and unexpected adverse events to the US Food and Drug Administration. December 4, 2016 Ma P, Marinovic I, Karaca-Mandic P. Drug Manufacturers' Delayed Disclosure of Serious and Unexpected Adverse Events to the US Food and Drug Administration. JAMA Intern Med. 2015;…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46475/psn-pdf
    April 16, 2018 - Incident reporting behaviours following the Francis report: a cross-sectional survey. April 16, 2018 Archer G, Colhoun A. Incident reporting behaviours following the Francis report: A cross-sectional survey. J Eval Clin Pract. 2017;24(2). doi:10.1111/jep.12849. https://psnet.ahrq.gov/issue/incident-reporting-behav…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866254/psn-pdf
    July 10, 2024 - Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. July 10, 2024 Massey W, Keith C. Spotlight PA: June 20, 2024. https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems- months-shutdown-then Whistleblowers…