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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41449/psn-pdf
    February 13, 2019 - Just Culture and its critical link to patient safety—part 1 and part 2. February 13, 2019 ISMP Medication Safety Alert! Acute Care Edition. May 17, 2012;17:1-4; July 12, 2012;17:1-3. https://psnet.ahrq.gov/issue/just-culture-and-its-critical-link-patient-safety-part-1-and-part-2 This newsletter article series pres…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838639/psn-pdf
    October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41453/psn-pdf
    November 26, 2014 - Judging whether a patient is actually improving: more pitfalls from the science of human perception. November 26, 2014 Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36087/psn-pdf
    September 28, 2010 - Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory. September 28, 2010 Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory. Health Serv Res. 2006;41(4 Pt 2):1654-76. https://psnet.ah…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867347/psn-pdf
    December 11, 2024 - Recommendations to ensure safety of AI in real-world clinical care. December 11, 2024 Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598. https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50374/psn-pdf
    September 25, 2019 - Explainable artificial intelligence for safe intraoperative decision support. September 25, 2019 Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821. https://psnet.ahrq.gov/issue/explainable-artificial-int…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44475/psn-pdf
    October 03, 2017 - Scoring no goal—further adventures in transparency. October 3, 2017 Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385- 8. doi:10.1056/NEJMp1510094. https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency This commentary explores challenges to mon…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47268/psn-pdf
    May 11, 2019 - Measuring shared mental models in healthcare. May 11, 2019 Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219. https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare Shared mental models are an important element of team collaboration. This review explores the current…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837346/psn-pdf
    June 08, 2022 - Decontamination of Surgical Instruments. June 8, 2022 Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022. https://psnet.ahrq.gov/issue/decontamination-surgical-instruments Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy mi…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73996/psn-pdf
    October 29, 2021 - Patient, Medical, and Legal Perspectives of Unsafe Care. October 20, 2021 Patient Safety Movement. October 29, 2021.  https://psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60965/psn-pdf
    September 30, 2020 - Data collection for adverse events reporting by US dental schools. September 30, 2020 Rooney D, Barrett K, Bufford B, et al. Data collection for adverse events reporting by US dental schools. J Patient Saf. 2020;16(3):e126-e130. doi:10.1097/pts.0000000000000281. https://psnet.ahrq.gov/issue/data-collection-adverse…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39749/psn-pdf
    August 11, 2010 - An evaluation of information transfer through the continuum of surgical care: a feasibility study. August 11, 2010 Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:10.1097/SLA.0b013e3181e986df. http…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73869/psn-pdf
    October 21, 2021 - Disrespectful behavior in healthcare: has it improved? Please take our survey! October 21, 2021 ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5. https://psnet.ahrq.gov/issue/disrespectful-behavior-healthcare-has-it-improved-please-take-our-survey Disrespectful behavior is a persisten…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33926/psn-pdf
    March 07, 2005 - The problems of detecting medication errors in hospitals. March 7, 2005 Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360. https://psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals Perhaps the f…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838015/psn-pdf
    September 07, 2022 - Physicians and cognitive decline: a challenge for state medical boards. September 7, 2022 Hoffman S. Physicians and cognitive decline: a challenge for state medical boards. J Med Regulation. 2022;108(2):19-28. doi:10.30770/2572-1852-108.2.19. https://psnet.ahrq.gov/issue/physicians-and-cognitive-decline-challenge-…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837430/psn-pdf
    June 15, 2022 - Stop using these adult bed rails, warns the Consumer Product Safety Commission. June 15, 2022 Treisman R. National Public Radio. June 6, 2022 https://psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission Bedrails are used in hospitals and at home to minimize falls despite t…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42564/psn-pdf
    September 11, 2013 - Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. September 11, 2013 Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1002/bjs.9168. https://psnet.ah…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848825/psn-pdf
    May 10, 2023 - Laura Levis' death outside ER has changed hospital signage, lighting in Mass. May 10, 2023 Mullins L, Menard F. WBUR. April 27, 2023. https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass Incomplete information and building design problems can reduce access to care an…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46746/psn-pdf
    March 07, 2018 - Safety with nebulized medications requires an interdisciplinary team approach. March 7, 2018 ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5. https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach Myriad system and clinician failures can con…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35022/psn-pdf
    June 22, 2009 - The investigation and analysis of critical incidents and adverse events in healthcare. June 22, 2009 Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii. https://psnet.ahrq.gov/issue/in…
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