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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40725/psn-pdf
    October 16, 2012 - Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. October 16, 2012 Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7. doi:10.10…
  2. psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
    June 24, 2020 - Commentary Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. Citation Text: Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. Copy Citation Format:…
  3. psnet.ahrq.gov/issue/strategies-learning-failure
    September 25, 2024 - Commentary Classic Strategies for learning from failure. Citation Text: Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  4. psnet.ahrq.gov/issue/patient-safety-7
    November 16, 2015 - Book/Report Patient Safety. Citation Text: Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I. Copy Citation Save Save to your library Print …
  5. psnet.ahrq.gov/issue/nurses-role-patient-safety
    June 09, 2011 - Commentary Nurses' role in patient safety. Citation Text: Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  6. psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
    July 15, 2010 - Review Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Citation Text: Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
  7. psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
    October 20, 2021 - Study Nursing student errors and near misses: three years of data. Citation Text: Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05. Copy Citation Format: DOI Google Scholar…
  8. psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
    March 23, 2011 - Study Ambulance stretcher adverse events. Citation Text: Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38956/psn-pdf
    March 18, 2015 - Safety in Doses. March 18, 2015 London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088. https://psnet.ahrq.gov/issue/safety-doses This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention. https://psnet.ahrq.gov…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41998/psn-pdf
    January 30, 2013 - Involving Patients in Improving Safety. January 30, 2013 London, UK: The Health Foundation; January 2013. https://psnet.ahrq.gov/issue/involving-patients-improving-safety This review analyzes research on engaging patients in safety improvement and details which strategies are most effective. https://psnet.ahrq.go…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39591/psn-pdf
    March 21, 2016 - Annual Benchmarking Report: Malpractice Risks in Surgery. March 21, 2016 Cambridge, MA: CRICO/RMF Strategies; 2010. https://psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of surgical c…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37765/psn-pdf
    May 24, 2015 - The Rebecca O'Malley Report. May 24, 2015 Cork, Ireland: Health Information and Quality Authority; March 21, 2008. https://psnet.ahrq.gov/issue/rebecca-omalley-report This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating sympto…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37560/psn-pdf
    March 28, 2018 - Learning from Investigations. March 28, 2018 Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. https://psnet.ahrq.gov/issue/learning-investigations Analyzing health care failures from 2004-2007 in the United Kingdom, this report identifies common them…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39848/psn-pdf
    April 16, 2018 - Diagnostic error in acute care. April 16, 2018 PA-PSRS Patient Saf Advis. September 2010;7:76-86.   https://psnet.ahrq.gov/issue/diagnostic-error-acute-care Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events. htt…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38151/psn-pdf
    March 18, 2010 - Medication errors associated with documented allergies. March 18, 2010 PA-PSRS Patient Saf Advis. September 2008;5:75-80.   https://psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies This article analyzed reports of medication errors due to patient allergies and found that lack of patient o…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40444/psn-pdf
    June 10, 2018 - Another tragic parenteral nutrition compounding error. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3. https://psnet.ahrq.gov/issue/another-tragic-parenteral-nutrition-compounding-error This article analyzes a fatal error involving parenteral nutrition and makes recommendation…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39981/psn-pdf
    November 03, 2010 - The path to safe and reliable healthcare. November 3, 2010 Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns. 2010;80(3). doi:10.1016/j.pec.2010.07.001. https://psnet.ahrq.gov/issue/path-safe-and-reliable-healthcare This commentary describes a model that aims to improve health car…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38730/psn-pdf
    June 24, 2009 - Errors in clinical reasoning: causes and remedial strategies. June 24, 2009 Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ. 2009;338:b1860. doi:10.1136/bmj.b1860. https://psnet.ahrq.gov/issue/errors-clinical-reasoning-causes-and-remedial-strategies This commentary analyzes how cogniti…
  19. psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
    November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …
  20. psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
    August 31, 2011 - Study Complication rates on weekends and weekdays in US hospitals. Citation Text: Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

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