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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74016/psn-pdf
    October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review. October 27, 2021 Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035. https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review Patien…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38747/psn-pdf
    September 16, 2009 - Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture. September 16, 2009 Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45251/psn-pdf
    August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong? August 24, 2016 Kowalczyk L. Boston Globe. August 14, 2016. https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series o…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74117/psn-pdf
    December 16, 2021 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals. November 24, 2021 Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021. https://psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals The release of the Workplace Safety supplemental items for…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837973/psn-pdf
    August 31, 2022 - Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff. August 31, 2022 Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff. PLoS ONE. 2022;17(6):e0269921. doi:10.1371/journal…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35374/psn-pdf
    January 02, 2017 - Intimidation: practitioners speak up about this unresolved problem. January 2, 2017 Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4. https://psnet.ahrq.gov/issue/intimidation-practitioners-s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44736/psn-pdf
    December 16, 2015 - Harms from discharge to primary care: mixed methods analysis of incident reports. December 16, 2015 Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687877. https://psnet.ahrq.gov/is…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74858/psn-pdf
    February 23, 2022 - Improving responses to safety incidents: we need to talk about justice. February 23, 2022 Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333. https://psnet.ahrq.gov/issue/improving-responses-safety-in…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838623/psn-pdf
    October 19, 2022 - Resident and nurse perspectives on the use of secure text messaging systems. October 19, 2022 Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953. https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40177/psn-pdf
    June 08, 2011 - Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. June 8, 2011 Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8. doi:1…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43485/psn-pdf
    December 15, 2014 - Implementation of an emergency department sign-out checklist improves transfer of information at shift change. December 15, 2014 Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg Med. 2014;47(5):580-5. doi:10…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853233/psn-pdf
    September 06, 2023 - Weight estimation for drug dose calculations in the prehospital setting - a systematic review. September 6, 2023 Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027. htt…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47456/psn-pdf
    April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. April 30, 2019 Horsham, PA: Institute for Safe Medication Practices; 2018. https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices Standardized practices have not been uniformly adopted to support safe IV medicati…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46479/psn-pdf
    October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts. October 4, 2017 Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395. https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts Applying evidence generated from complaints submitted to h…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44170/psn-pdf
    May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety Culture. May 29, 2023 Rockville, MD: Agency for Healthcare Research and Quality; October 2020. https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73077/psn-pdf
    March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44330/psn-pdf
    September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop Summary. September 2, 2015 Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN: 9780309371544. https://psnet.…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38663/psn-pdf
    May 27, 2009 - Prevention of retained surgical sponges: a decision- analytic model predicting relative cost-effectiveness. May 27, 2009 Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision- analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35. doi:10.1016…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42997/psn-pdf
    May 28, 2014 - Exploring perinatal shift-to-shift handover communication and process: an observational study. May 28, 2014 Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103. https:/…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39356/psn-pdf
    April 08, 2011 - Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. April 8, 2011 Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…

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