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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36357/psn-pdf
    December 19, 2009 - Error reporting in organizations. December 19, 2009 Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030. https://psnet.ahrq.gov/issue/error-reporting-organizations The authors provide a framework for individual error reporting behavior that follows three phases: error detection, situation assessment, and choic…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35765/psn-pdf
    September 14, 2008 - Manchester Patient Safety Framework (MaPSaF). September 14, 2008 Manchester, UK: University of Manchester; 2006. https://psnet.ahrq.gov/issue/manchester-patient-safety-framework-mapsaf This tool was developed to help National Health Service organizations assess their progress in implementing and sustaining a safet…

  3. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36584/psn-pdf
    January 12, 2011 - Will my patient fall? January 12, 2011 Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007;297(1):77-86. https://psnet.ahrq.gov/issue/will-my-patient-fall The authors assessed the literature to determine risk factors for falls that can be identified to help prevent such injuries. https://psnet.ah…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38320/psn-pdf
    July 28, 2013 - State of Healthcare 2008. July 28, 2013 Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9780102958362. https://psnet.ahrq.gov/issue/state-healthcare-2008 This report assesses care in the United Kingdom, provides data on a variety of issues related to safety, and …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36336/psn-pdf
    October 26, 2010 - Interprofessional Approaches to Patient Safety. October 26, 2010 J Interprof Care. 2006;20(5):461-563. https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety This issue includes articles that explore successful multidisciplinary efforts to improve patient safety, including medication risk assessm…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36534/psn-pdf
    March 09, 2009 - Standardizing hand-off processes. March 9, 2009 Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61. https://psnet.ahrq.gov/issue/standardizing-hand-processes The author suggests ways to improve hand-off communications and provides an assessment form to assist staff in detecting weaknesses in…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38367/psn-pdf
    May 24, 2015 - Pathways for Patient Safety. May 24, 2015 Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009. https://psnet.ahrq.gov/issue/pathways-patient-safety This trio of modules provides ambulatory medical practices with tools to develop te…

  9. 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…

  10. 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…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60066/psn-pdf
    March 25, 2020 - No further nursing assessments or vital signs were recorded until 5:40am when the patient became increasingly

  12. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet

    psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
    November 25, 2020 - No further nursing assessments or vital signs were recorded until 5:40am when the patient became increasingly

  13. 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…

  14. 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…

  15. 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…

  16. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. | PSNet

    psnet.ahrq.gov/issue/validity-unplanned-admission-intensive-care-unit-measure-patient-safety-surgical-patients
    May 26, 2021 - Study Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Citation Text: Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthe…

  17. Transforming the medication regimen review process using telemedicine to prevent adverse events. | PSNet

    psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events
    November 11, 2015 - Study Transforming the medication regimen review process using telemedicine to prevent adverse events. Citation Text: Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…

  18. A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? | PSNet

    psnet.ahrq.gov/issue/literature-review-training-offered-qualified-prescribers-use-electronic-prescribing-systems
    December 21, 2022 - Review A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? Citation Text: Brown CL, Reygate K, Slee A, et al. A literature review of the training offered to qualified prescribers to use electronic prescribing…

  19. High-priority drug–drug interactions for use in electronic health records. | PSNet

    psnet.ahrq.gov/issue/high-priority-drug-drug-interactions-use-electronic-health-records
    September 01, 2016 - Study High-priority drug–drug interactions for use in electronic health records. Citation Text: Phansalkar S, Desai AA, Bell D, et al. High-priority drug-drug interactions for use in electronic health records. J Am Med Inform Assoc. 2012;19(5):735-43. doi:10.1136/amiajnl-2011-000612. C…

  20. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. | PSNet

    psnet.ahrq.gov/issue/comparative-accuracy-diagnosis-collective-intelligence-multiple-physicians-vs-individual
    January 23, 2017 - Study Emerging Classic Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. Citation Text: Barnett ML, Boddupalli D, Nundy S, et al. Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple…
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