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3281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49483/psn-pdf
      June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

3282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33959/psn-pdf
      January 17, 2012 - Healthcare Failure Mode and Effect Analysis. January 17, 2012 National Center for Patient Safety. https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, a…

3283. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42701/psn-pdf
      June 27, 2018 - Improving reliability with root cause analysis. June 27, 2018 Latino RJ https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis This article relates how root cause analysis, typically used after an adverse event, can be utilized as a proactive risk assessment tool to enhance reliability. https://ps…

3284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37085/psn-pdf
      July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and Technology. July 15, 2013 Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258. https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology This guide provides comprehensive tools for assessment, training, and imple…

3285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36677/psn-pdf
      February 21, 2007 - Hospitals win safety award for simple changes.  February 21, 2007 Sipkoff M. Drug Topics. January 22, 2007. https://psnet.ahrq.gov/issue/hospitals-win-safety-award-simple-changes This article spotlights two Philadelphia hospitals recognized for their innovative medication safety initiatives: use of color-coded sto…

3286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36271/psn-pdf
      September 20, 2006 - Safe Foundations: Junior Doctors and Patient Safety. September 20, 2006 National Patient Safety Agency. https://psnet.ahrq.gov/issue/safe-foundations-junior-doctors-and-patient-safety This Web site has educational modules for doctors-in-training and provides slides, trainer's notes, and relevant case studies on hu…

3287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35820/psn-pdf
      December 31, 2018 - Simulation in Healthcare. December 31, 2018 Scerbo M, ed. Washington DC; Society for Simulation in Healthcare, Lippincott, Williams and Wilkins. ISSN: 1559-2332 https://psnet.ahrq.gov/issue/simulation-healthcare This bi-monthly peer-reviewed journal presents multidisciplinary content on how simulation is being use…

3288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35232/psn-pdf
      December 09, 2008 - Patient safety: is it just another bandwagon? December 9, 2008 Storch JL. Patient safety: is it just another bandwagon? Nurs Leadersh (Tor Ont). 2005;18(2):39-55. https://psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon The author advocates critical assessment of the patient safety movement and suggest…

3289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43314/psn-pdf
      August 15, 2018 - ISQua Fellowship Programme. August 15, 2018 International Society for Quality in Health Care. https://psnet.ahrq.gov/issue/isqua-fellowship-programme This announcement highlights a peer learning initiative that builds on existing programs and interdisciplinary networks to develop participants' understanding about …

3290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34574/psn-pdf
      March 07, 2005 - Safe Handling of Hazardous Drugs. March 7, 2005 Polovich M; Blecher CS; Glynn-Tucker EM; McDiarmid M; Newton SA https://psnet.ahrq.gov/issue/safe-handling-hazardous-drugs This guideline provides recommendations to enhance the safe delivery of high-risk medications. Topics include assessing occupational exposure ri…

3291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35484/psn-pdf
      February 22, 2010 - The development of a patient safety program across the continuum of care. February 22, 2010 Wertenberger S, Wilson J. The development of a patient safety program across the continuum of care. Nurs Adm Q. 2005;29(4):303-307. https://psnet.ahrq.gov/issue/development-patient-safety-program-across-continuum-care The …

3292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36287/psn-pdf
      September 20, 2006 - Nursing Home Complaint Investigations.  September 20, 2006 Levinson DR. Washington DC: Office of the Inspector General; July 2006. OEI-01-04-00340. https://psnet.ahrq.gov/issue/nursing-home-complaint-investigations This report shares findings from an assessment of Centers for Medicaid and Medicare Services response…

3293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36669/psn-pdf
      January 18, 2011 - A review of organizational culture instruments for nurse executives. January 18, 2011 King T, Byers JF. A review of organizational culture instruments for nurse executives. J Nurs Adm. 2007;37(1):21-31. https://psnet.ahrq.gov/issue/review-organizational-culture-instruments-nurse-executives The authors compare too…

3294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38031/psn-pdf
      September 03, 2008 - Development and evaluation of a required patient safety course.  September 3, 2008 Sukkari SR, Sasich LD, Tuttle DA, et al. Development and evaluation of a required patient safety course. Am J Pharm Educ. 2008;72(3):65. https://psnet.ahrq.gov/issue/development-and-evaluation-required-patient-safety-course This ar…

3295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33903/psn-pdf
      November 28, 2018 - ECRI Guidelines Trust. November 28, 2018 ECRI Institute. https://psnet.ahrq.gov/issue/ecri-guidelines-trust This website is a practical resource to review existing clinical practice guidelines in a centralized location. Key components of the site include links to full-text guidelines and an assessment function tha…

3296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35509/psn-pdf
      January 17, 2025 - Patient Safety Awareness Week. January 17, 2025 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/patient-safety-awareness-week This website provides resources for promoting patient safety during Patient Safety Awareness Week, including a webinar archive, selected readings and communication strate…

3297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35579/psn-pdf
      November 26, 2008 - Perioperative Issues for Surgeons: Improving Patient Safety and Outcomes. November 26, 2008 Napolitano LM, ed. Surg Clin North Am. 2005;85(6):1061-1380. https://psnet.ahrq.gov/issue/perioperative-issues-surgeons-improving-patient-safety-and-outcomes This issue focuses on the safety of surgical patients, with artic…

3298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35472/psn-pdf
      September 21, 2009 - Clinical alarms: improving efficiency and effectiveness. September 21, 2009 Phillips J, Barnsteiner JH. Clinical alarms: improving efficiency and effectiveness. Crit Care Nurs Q. 2005;28(4):317-323. https://psnet.ahrq.gov/issue/clinical-alarms-improving-efficiency-and-effectiveness The authors outline a process fo…

3299. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

3300. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33693/psn-pdf
      February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety February 1, 2010 Baron RB, Vidyarthi A. The Role of Graduate Medical Education (GME) in Improving Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety Perspec…