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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38734/psn-pdfJuly 01, 2009 - Safety and efficiency considerations for the introduction of electronic ordering in a blood bank. July 1, 2009 Georgiou A, Greenfield T, Callen J, et al. Safety and efficiency considerations for the introduction of electronic ordering in a blood bank. Arch Pathol Lab Med. 2009;133(6):933-7. doi:10.1043/1543-2165- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36637/psn-pdfJanuary 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36026/psn-pdfMarch 28, 2011 - Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. March 28, 2011 Kunac DL, Reith DM, Kennedy J, et al. Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. Qual Saf Health Care. 2006;15(3):196-201. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43720/psn-pdfNovember 26, 2014 - Hamilton father misdiagnosed with lung cancer demands answers. November 26, 2014 Carville O. The Star. November 14, 2014. https://psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866869/psn-pdfOctober 02, 2024 - Core Elements of Hospital Diagnostic Excellence (DxEx). October 2, 2024 Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex Diagnostic excellence is an expansion of the diagnostic error red… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43985/psn-pdfDecember 06, 2017 - Development of a medication safety and quality survey for small rural hospitals. December 6, 2017 Winterstein AG, Johns TE, Campbell KN, et al. Development of a Medication Safety and Quality Survey for Small Rural Hospitals. J Patient Saf. 2017;13(4):249-254. doi:10.1097/PTS.0000000000000154. https://psnet.ahrq.go… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60885/psn-pdfSeptember 02, 2020 - Becoming a High Reliability Organization. September 2, 2020 VHA Forum. Summer 2020;1-12. https://psnet.ahrq.gov/issue/becoming-high-reliability-organization High reliability attainment is a stated goal for health care organizations. This special issue covers established initiatives at the United States Veterans He… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37746/psn-pdfMay 14, 2008 - Reducing preventable medication safety events by recognizing renal risk. May 14, 2008 Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476.2f. https://psnet.ahrq.gov/issue/red… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45185/psn-pdfAugust 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48128/psn-pdfAugust 28, 2019 - Burnout in healthcare: the case for organisational change. August 28, 2019 Montgomery A, Panagopoulou E, Esmail A, et al. Burnout in healthcare: the case for organisational change. BMJ. 2019;366:l4774. doi:10.1136/bmj.l4774. https://psnet.ahrq.gov/issue/burnout-healthcare-case-organisational-change Burnout has be… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45659/psn-pdfNovember 16, 2016 - Misdiagnoses: a hidden risk of genetic testing. November 16, 2016 Howard J. CNN. October 31, 2016. https://psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary care. This news article reports on the un… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34816/psn-pdfFebruary 28, 2018 - Blaming others for threatening events. February 28, 2018 Tennen H; Affleck G. https://psnet.ahrq.gov/issue/blaming-others-threatening-events This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations f… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43020/psn-pdfMay 29, 2014 - Handoff practices in undergraduate medical education. May 29, 2014 Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0. https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education This su… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45006/psn-pdfApril 06, 2016 - Quality and Patient Safety. April 6, 2016 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/quality-and-patient-safety The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide rang… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50646/psn-pdfNovember 06, 2019 - My patient almost died from a mistake I made. I apologized and it changed my life. November 6, 2019 McLean K. Huffington Post. October 16, 2019. https://psnet.ahrq.gov/issue/my-patient-almost-died-mistake-i-made-i-apologized-and-it-changed-my-life Medical mistakes cause stress for both patients and their clinician… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73991/psn-pdfOctober 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42387/psn-pdfDecember 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 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46997/psn-pdfJuly 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866934/psn-pdfOctober 09, 2024 - How America’s health care system fails women in pain. October 9, 2024 Neklason A. How America’s health care system fails women in pain. The Hill. September 23, 2024; https://psnet.ahrq.gov/issue/how-americas-health-care-system-fails-women-pain Appropriate treatment of pain is a complicated process vulnerable to rac… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45849/psn-pdfFebruary 22, 2017 - Monitoring teamwork: a narrative review. February 22, 2017 Rutherford JS. Monitoring teamwork: a narrative review. Anaesthesia. 2017;72 Suppl 1:84-94. doi:10.1111/anae.13744. https://psnet.ahrq.gov/issue/monitoring-teamwork-narrative-review Anesthesiology was an early adopter of teamwork as a safety improvement st…
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