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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45828/psn-pdf
    April 13, 2017 - Interpretive error in radiology. April 13, 2017 Waite S, Scott JM, Gale B, et al. Interpretive Error in Radiology. AJR Am J Roentgenol. 2017;208(4):739- 749. doi:10.2214/AJR.16.16963. https://psnet.ahrq.gov/issue/interpretive-error-radiology Interpretive radiology errors can result in delays that contribute to pat…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837907/psn-pdf
    August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings Medication errors associated with surgery and…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44909/psn-pdf
    March 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. March 23, 2016 Horsham, PA: Institute for Safe Medication Practices; 2013. https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis offers a structured way to detect and address system weaknesses. This…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39978/psn-pdf
    November 03, 2010 - Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education. November 3, 2010 Christiansen A, Robson L, Griffith-Evans C. Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education. J Nurs Manag…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37556/psn-pdf
    November 21, 2016 - Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. November 21, 2016 Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. doi:10.1001/archsurg.2007.27. https:/…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42405/psn-pdf
    July 10, 2013 - The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. July 10, 2013 Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):411-5. doi:10.1016/j.ejim.2013.01.022. ht…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43839/psn-pdf
    January 28, 2015 - Patient Safety. January 28, 2015 J Health Serv Res Policy. 2015;20(suppl 1):S1-S60. https://psnet.ahrq.gov/issue/patient-safety-11 Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how orga…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44358/psn-pdf
    September 24, 2016 - Interruptions and medication administration in critical care. September 24, 2016 Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit Care. 2015;20(4):183-95. doi:10.1111/nicc.12185. https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35943/psn-pdf
    August 02, 2010 - Follow-up of outpatient test results: a survey of house- staff practices and perceptions. August 2, 2010 Lin JJ, Dunn A, Moore C. Follow-up of outpatient test results: a survey of house-staff practices and perceptions. Am J Med Qual. 2006;21(3):178-84. https://psnet.ahrq.gov/issue/follow-outpatient-test-results-su…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43493/psn-pdf
    February 18, 2015 - Hospital tones down alarms to reduce fatigue, enhance safety. February 18, 2015 Olson J. https://psnet.ahrq.gov/issue/hospital-tones-down-alarms-reduce-fatigue-enhance-safety Alarm fatigue has been recognized as a contributor to serious errors in hospitals. Reporting on how nuisance alarms increase risks, this ne…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851455/psn-pdf
    July 19, 2023 - Student mistakes and teacher reactions in bedside teaching. July 19, 2023 Rubisch HPK, Blaschke A-L, Berberat PO, et al. Student mistakes and teacher reactions in bedside teaching. Adv Health Sci Educ Theory Pract. 2023;28(5):1523-1556. doi:10.1007/s10459-023-10233-y. https://psnet.ahrq.gov/issue/student-mistakes-…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43051/psn-pdf
    May 29, 2014 - A just culture after Mid Staffordshire. May 29, 2014 Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. doi:10.1136/bmjqs-2013-002483. https://psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire In the context of public reactions to the Francis report, this commentar…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44298/psn-pdf
    July 08, 2015 - Preparing challenging medications for barcode scanning. July 8, 2015 Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454. https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning Barcode scanning can reduce me…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46838/psn-pdf
    March 07, 2018 - Behavioral & Mental Health Toolbox. March 7, 2018 Center for Health Design. Concord, CA: Center for Health Design; 2018. https://psnet.ahrq.gov/issue/behavioral-mental-health-toolbox Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33962/psn-pdf
    June 22, 2007 - Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements. June 22, 2007 HB 1602. Washington State Legislature. 2003-2004. https://psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hosp…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849130/psn-pdf
    May 17, 2023 - Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. May 17, 2023 Powell M. J Health Org Manag. 2023;37(1):67-83. https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry Individual, team, and organizational willingness to identify and add…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845351/psn-pdf
    March 01, 2023 - Access to Clinical Information at the Bedside. March 1, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; February 2023. https://psnet.ahrq.gov/issue/access-clinical-information-bedside Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety. This rep…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42031/psn-pdf
    February 06, 2013 - Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. February 6, 2013 Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 2012;19(12):1454-61. doi:10.1111/acem.1203…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46944/psn-pdf
    March 21, 2018 - Critical Deficiencies at the Washington DC VA Medical Center. March 21, 2018 Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130. https://psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center Systemic weaknesses in the Veterans A…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865493/psn-pdf
    April 03, 2024 - Implement strategies to prevent persistent medication errors and hazards: 2024. April 3, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024 Systemic failures can perpetuate unsafe care if a lack of p…
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