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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47304/psn-pdf
    October 24, 2018 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. October 24, 2018 Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014. https://psnet.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48053/psn-pdf
    July 17, 2019 - Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. July 17, 2019 Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. Aust Health …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39264/psn-pdf
    February 03, 2010 - Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. February 3, 2010 Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review. Crit Care Med. 2010;38(2):445…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43500/psn-pdf
    November 17, 2014 - A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application? November 17, 2014 Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and applica…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45243/psn-pdf
    September 14, 2016 - Incidence of speech recognition errors in the emergency department. September 14, 2016 Goss FR, Zhou L, Weiner SG. Incidence of speech recognition errors in the emergency department. Int J Med Inform. 2016;93:70-73. doi:10.1016/j.ijmedinf.2016.05.005. https://psnet.ahrq.gov/issue/incidence-speech-recognition-error…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34665/psn-pdf
    December 24, 2008 - Organizational learning: health care leaders need to design structures and processes that enhance collective learning. December 24, 2008 Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-d…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44466/psn-pdf
    September 16, 2015 - Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. September 16, 2015 Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a re…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849324/psn-pdf
    May 24, 2023 - Learning from errors and resilience. May 24, 2023 Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/aco.0000000000001257. https://psnet.ahrq.gov/issue/learning-errors-and-resilience The Safety II framework and organizational resilience b…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34814/psn-pdf
    January 01, 2015 - Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. March 28, 2005 Nolan L, O'Malley K. Prescribing for the Elderly Part I: Sensitivity of the Elderly to Adverse Drug Reactions*. J Am Geriatr Soc. 2015;36(2):142-149. doi:10.1111/j.1532-5415.1988.tb01785.x. https://psnet.ahrq.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47375/psn-pdf
    November 02, 2018 - Ethical duty of health care systems to address interfacility medical error discovery. November 2, 2018 Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.jamcollsurg.2018.08.184. https://psn…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46176/psn-pdf
    October 04, 2017 - Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit. October 4, 2017 Hermanspann T, Schoberer M, Robel-Tillig E, et al. Incidence and Severity of Prescribing Errors in Parenteral Nutrition for Pediatric Inpatients at a Neonat…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50922/psn-pdf
    February 19, 2020 - An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020 Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020. https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation- monitoring-and-regul…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60525/psn-pdf
    May 27, 2020 - Public sector organizational failure: a study of collective denial in the UK national health service. May 27, 2020 Hendy J, Tucker DA. Public sector organizational failure: a study of collective denial in the UK national health service. J Bus Ethics. 2020;2021;172:691–706. doi:10.1007/s10551-020-04517-1. https://p…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44705/psn-pdf
    January 01, 2017 - Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods study. December 7, 2016 Song H, Ryan M, Tendulkar S, et al. Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study. Health…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844057/psn-pdf
    February 08, 2023 - Impact of medical education on patient safety: finding the signal through the noise. February 8, 2023 Hwang J, Kelz RR. Impact of medical education on patient safety: finding the signal through the noise. BMJ Qual Saf. 2023;32(2):61-64. doi:10.1136/bmjqs-2022-015054. https://psnet.ahrq.gov/issue/impact-medical-edu…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39621/psn-pdf
    June 23, 2010 - Defining near misses: towards a sharpened definition based on empirical data about error handling processes. June 23, 2010 Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):130…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46669/psn-pdf
    January 17, 2018 - Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population. January 17, 2018 Wang JS, Fogerty RL, Horwitz LI. Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population. P…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837433/psn-pdf
    June 15, 2022 - Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg. June 15, 2022 Bamberger E, Bamberger P. Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg. BMJ Qual Saf. 2022;31(9):638-641. doi:10.1136/bmjqs-2021-014157. https://psnet.ahrq…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46933/psn-pdf
    April 04, 2018 - Pain states, the opioid epidemic, and the role of radiologists. April 4, 2018 Jones MR, Kaye AD, Manchikanti L, et al. Pain States, the Opioid Epidemic, and the Role of Radiologists. Curr Pain Headache Rep. 2018;22(3):20. doi:10.1007/s11916-018-0672-x. https://psnet.ahrq.gov/issue/pain-states-opioid-epidemic-and-r…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44869/psn-pdf
    November 18, 2016 - Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. November 18, 2016 Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…