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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42414/psn-pdf
    July 31, 2013 - Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. … Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. … https://psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response- system-collaborative … https://psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response-system-collaborative … https://psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response-system-collaborative
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34954/psn-pdf
    June 23, 2009 - Active surveillance of vaccine safety: a system to detect early signs of adverse events. … Active surveillance of vaccine safety: a system to detect early signs of adverse events. … https://psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events … The surveillance system accurately captured adverse events, which supports the viability of similar … https://psnet.ahrq.gov/issue/active-surveillance-vaccine-safety-system-detect-early-signs-adverse-events
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36163/psn-pdf
    September 29, 2010 - Improving the bar-coded medication administration system at the Department of Veterans Affairs. … Improving the bar-coded medication administration system at the Department of Veterans Affairs. … https://psnet.ahrq.gov/issue/improving-bar-coded-medication-administration-system-department-veterans … The authors present the challenges that developed in the Veterans Affairs system after implementation … https://psnet.ahrq.gov/issue/improving-bar-coded-medication-administration-system-department-veterans-affairs
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38748/psn-pdf
    April 19, 2011 - Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in … Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in … https://psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide … https://psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide-causes-falls … https://psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide-causes-falls
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35995/psn-pdf
    October 28, 2010 - FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment … https://psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment- guidance-reduce … https://psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce … https://psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce … https://psnet.ahrq.gov/issue/hospital-bed-system-dimensional-and-assessment-guidance-reduce-entrapment
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35982/psn-pdf
    September 17, 2010 - Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS). … Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS). … https://psnet.ahrq.gov/issue/follow-study-medication-errors-reported-vaccine-adverse-event-reporting- system-vaers … https://psnet.ahrq.gov/issue/follow-study-medication-errors-reported-vaccine-adverse-event-reporting-system-vaers … https://psnet.ahrq.gov/issue/follow-study-medication-errors-reported-vaccine-adverse-event-reporting-system-vaers
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37338/psn-pdf
    January 02, 2017 - Using the rapid response system to provide better oversight of patient care processes. … Using the rapid response system to provide better oversight of patient care processes. … https://psnet.ahrq.gov/issue/using-rapid-response-system-provide-better-oversight-patient-care-processes … The authors found that the rapid response system allowed staff to identify a recurrent error and consequently … https://psnet.ahrq.gov/issue/using-rapid-response-system-provide-better-oversight-patient-care-processes
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39966/psn-pdf
    February 01, 2011 - Journey to no preventable risk: The Baylor Health Care System patient safety experience. … Journey to no preventable risk: the Baylor Health Care System patient safety experience. … https://psnet.ahrq.gov/issue/journey-no-preventable-risk-baylor-health-care-system-patient-safety- experience … https://psnet.ahrq.gov/issue/journey-no-preventable-risk-baylor-health-care-system-patient-safety-experience … https://psnet.ahrq.gov/issue/journey-no-preventable-risk-baylor-health-care-system-patient-safety-experience
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36800/psn-pdf
    August 26, 2011 - Application of the human factors analysis and classification system methodology to the cardiovascular … Application of the human factors analysis and classification system methodology to the cardiovascular … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42173/psn-pdf
    April 24, 2013 - Hand hygiene and healthcare system change within multi- modal promotion: a narrative review. … Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. … https://psnet.ahrq.gov/issue/hand-hygiene-and-healthcare-system-change-within-multi-modal-promotion- … https://psnet.ahrq.gov/issue/hand-hygiene-and-healthcare-system-change-within-multi-modal-promotion-narrative-review … https://psnet.ahrq.gov/issue/hand-hygiene-and-healthcare-system-change-within-multi-modal-promotion-narrative-review
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36981/psn-pdf
    September 14, 2011 - A new infusion syringe label system designed to reduce task complexity during drug preparation. … A new infusion syringe label system designed to reduce task complexity during drug preparation. … https://psnet.ahrq.gov/issue/new-infusion-syringe-label-system-designed-reduce-task-complexity-during … https://psnet.ahrq.gov/issue/new-infusion-syringe-label-system-designed-reduce-task-complexity-during-drug-preparation … https://psnet.ahrq.gov/issue/new-infusion-syringe-label-system-designed-reduce-task-complexity-during-drug-preparation
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39675/psn-pdf
    January 19, 2011 - A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. … A 5-year analysis of rapid response system activation at an in- hospital haemodialysis unit. … https://psnet.ahrq.gov/issue/5-year-analysis-rapid-response-system-activation-hospital-haemodialysis-unit … This review of rapid response system calls to an inpatient hemodialysis unit found that many events … https://psnet.ahrq.gov/issue/5-year-analysis-rapid-response-system-activation-hospital-haemodialysis-unit
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36309/psn-pdf
    January 05, 2017 - The medical emergency team and rapid response system: finding, treating, and preventing hypoglycemia … The medical emergency team and rapid response system: finding, treating, and preventing hypoglycemia … https://psnet.ahrq.gov/issue/medical-emergency-team-and-rapid-response-system-finding-treating-and- … https://psnet.ahrq.gov/issue/medical-emergency-team-and-rapid-response-system-finding-treating-and-preventing-hypoglycemia … https://psnet.ahrq.gov/issue/medical-emergency-team-and-rapid-response-system-finding-treating-and-preventing-hypoglycemia
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34589/psn-pdf
    January 04, 2017 - System innovation: Veterans Health Administration National Center for Patient Safety. … System innovation: Veterans Health Administration National Center for Patient Safety. … https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-veterans-health … https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-veterans-health-administration … https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-veterans-health-administration
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38595/psn-pdf
    June 15, 2011 - Implementation of a patient safety incident management system as viewed by doctors, nurses and allied … Implementation of a patient safety incident management system as viewed by doctors, nurses and allied … https://psnet.ahrq.gov/issue/implementation-patient-safety-incident-management-system-viewed-doctors- … https://psnet.ahrq.gov/issue/implementation-patient-safety-incident-management-system-viewed-doctors-nurses-and-allied … https://psnet.ahrq.gov/issue/implementation-patient-safety-incident-management-system-viewed-doctors-nurses-and-allied
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47485/psn-pdf
    January 09, 2019 - System-related and cognitive errors in laboratory medicine. January 9, 2019 Plebani M. … System-related and cognitive errors in laboratory medicine. … https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine Problems managing … This commentary discusses several approaches to decrease system and cognitive errors in clinical laboratories … https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine https://psnet.ahrq.gov
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42446/psn-pdf
    May 19, 2014 - The Human Factors Analysis Classification System (HFACS) applied to health care. … The Human Factors Analysis Classification System (HFACS) applied to health care. … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care … This study reports on one health system's experience using the Human Factors Analysis Classification System … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care https
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33727/psn-pdf
    March 01, 2012 - Can Research Help Us Improve the Medical Liability System? March 1, 2012 Kachalia A. … Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012. … https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system Perspective … The United States medical malpractice liability system continues to frustrate physicians and patients … System failure versus personal accountability—the case for clean hands.
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36226/psn-pdf
    August 30, 2006 - Framework for a High Performance Health System for the United States. August 30, 2006 Mongan JJ. … https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states This report calls … The authors ascribe the current quality problems in the U.S. health care system to system failures, … https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states https://psnet.ahrq.gov
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39459/psn-pdf
    March 23, 2011 - Impact of system-level activities and reporting design on the number of incident reports for patient … Impact of system-level activities and reporting design on the number of incident reports for patient … https://psnet.ahrq.gov/issue/impact-system-level-activities-and-reporting-design-number-incident-reports … https://psnet.ahrq.gov/issue/impact-system-level-activities-and-reporting-design-number-incident-reports-patient-safety … https://psnet.ahrq.gov/issue/impact-system-level-activities-and-reporting-design-number-incident-reports-patient-safety

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