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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42943/psn-pdf
    April 12, 2014 - Doing right by our patients when things go wrong in the ambulatory setting. April 12, 2014 Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96. https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42387/psn-pdf
    December 30, 2014 - 'Bad apples': time to redefine as a type of systems problem? December 30, 2014 Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138. https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem While …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45931/psn-pdf
    July 05, 2017 - The CARE approach to reducing diagnostic errors. July 5, 2017 Rush JL, Helms SE, Mostow EN. The CARE approach to reducing diagnostic errors. Int J Dermatol. 2017;56(6):669-673. doi:10.1111/ijd.13532. https://psnet.ahrq.gov/issue/care-approach-reducing-diagnostic-errors Cognitive aids such as checklists and mnemoni…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35053/psn-pdf
    November 18, 2015 - Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety. November 18, 2015 Yeager KR, Saveanu R, Roberts AR, et al. Brief Treat Crisis Intervent. 2005;5(2):121-141 https://psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36016/psn-pdf
    September 27, 2016 - Strategies used by nurses to recover medical errors in an academic emergency department setting. September 27, 2016 Henneman EA, Blank FSJ, Gawlinski A, et al. Strategies used by nurses to recover medical errors in an academic emergency department setting. Appl Nurs Res. 2006;19(2):70-7. https://psnet.ahrq.gov/iss…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38521/psn-pdf
    September 19, 2016 - Inpatient suicide: preventing a common sentinel event. September 19, 2016 Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. Gen Hosp Psychiatry. 2009;31(2):103-9. doi:10.1016/j.genhosppsych.2008.09.007. https://psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event Suici…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73991/psn-pdf
    October 20, 2021 - Digital Clinical Safety Strategy October 20, 2021 NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021. https://psnet.ahrq.gov/issue/digital-clinical-safety-strategy Digital clinical technologies hold promise for care improvement while contributing to potential failures due to th…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40599/psn-pdf
    November 23, 2011 - Organizational climate determinants of resident safety culture in nursing homes. November 23, 2011 Arnetz JE, Zhdanova LS, Elsouhag D, et al. Organizational climate determinants of resident safety culture in nursing homes. Gerontologist. 2011;51(6):739-49. doi:10.1093/geront/gnr053. https://psnet.ahrq.gov/issue/or…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60538/psn-pdf
    May 27, 2020 - Diagnostic Safety Toolkit. May 27, 2020 Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020. https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit Effective communication is an important component of diagnostic accuracy. Shaped with data co…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60663/psn-pdf
    January 01, 2021 - Apology laws and malpractice liability: what have we learned? July 8, 2020 Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual Saf. 2021;30(1):64-67. doi:10.1136/bmjqs-2020-010955. https://psnet.ahrq.gov/issue/apology-laws-and-malpractice-liability-what-have-we-l…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50643/psn-pdf
    November 06, 2019 - Same Day Surgery in the US; Findings of Two Inaugural Leapfrog Surveys 2019. November 6, 2019 Washington DC: Leapfrog Group; 2019. https://psnet.ahrq.gov/issue/same-day-surgery-us-findings-two-inaugural-leapfrog-surveys-2019 Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45899/psn-pdf
    March 15, 2017 - Patient Safety: Investigating and Reporting Serious Clinical Incidents. March 15, 2017 Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169. https://psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents Research is increasingly focusing on patient safety in primary ca…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40098/psn-pdf
    December 18, 2014 - Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. December 18, 2014 Ligi I, Millet V, Sartor C, et al. Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. Pediatrics. 2010;126(6):e1461-8. doi:10.1542/peds.2009-2872…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45185/psn-pdf
    August 03, 2016 - Final Report of the Commission on Care. August 3, 2016 Washington, DC: Commission on Care; June 2016. https://psnet.ahrq.gov/issue/final-report-commission-care The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future stat…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46997/psn-pdf
    July 25, 2018 - Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review. July 25, 2018 Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018. https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-healthcare-report-rapid-policy-review Accountability for errors and or…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37312/psn-pdf
    January 05, 2012 - Delineation of risk through the exploration of a culture of safety in community home health. January 5, 2012 Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:10.1177/1084822307304256. https://…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73989/psn-pdf
    October 20, 2021 - How is safety climate measured? A review and evaluation. October 20, 2021 Shea T, De Cieri H, Vu T, et al. How is safety climate measured? A review and evaluation. Safety Sci. 2021;143:105413. doi:10.1016/j.ssci.2021.105413. https://psnet.ahrq.gov/issue/how-safety-climate-measured-review-and-evaluation Assessing s…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836832/psn-pdf
    March 30, 2022 - Improving Education—A Key to Better Diagnostic Outcomes. March 30, 2022 Olson APJ, Danielson J, Stanley J, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF https://psnet.ahrq.gov/issue/improving-education-key-better-diagnostic-outcomes Diagnostic skil…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36637/psn-pdf
    January 14, 2011 - The effect of the fit between organizational culture and structure on medication errors in medical group practices. January 14, 2011 Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on medication errors in medical group practices. Health Care Manage Rev. 2007…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838079/psn-pdf
    September 14, 2022 - Exploring the impact of employee engagement and patient safety. September 14, 2022 Scott G, Hogden A, Taylor R, et al. Exploring the impact of employee engagement and patient safety. Int J Qual Health Care. 2022;34(3):mzac059. doi:10.1093/intqhc/mzac059. https://psnet.ahrq.gov/issue/exploring-impact-employee-engag…
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