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  1. 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…

  2. 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…

  3. 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…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46158/psn-pdf
    October 31, 2017 - Improving care teams' functioning: recommendations from team science. October 31, 2017 Fiscella K, Mauksch L, Bodenheimer T, et al. Improving Care Teams' Functioning: Recommendations from Team Science. Jt Comm J Qual Patient Saf. 2017;43(7):361-368. doi:10.1016/j.jcjq.2017.03.009. https://psnet.ahrq.gov/issue/impr…

  5. 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 …

  6. 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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45951/psn-pdf
    October 31, 2017 - A systematic review of team training in health care: ten questions. October 31, 2017 Marlow SL, Hughes A, Sonesh SC, et al. A Systematic Review of Team Training in Health Care: Ten Questions. Jt Comm J Qual Patient Saf. 2017;43(4):197-204. doi:10.1016/j.jcjq.2016.12.004. https://psnet.ahrq.gov/issue/systematic-rev…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36671/psn-pdf
    January 18, 2011 - Increasing vigilance on the medical/surgical floor to improve patient safety. January 18, 2011 Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x. https://psnet.ahrq.gov/issue/increasing-vigilance-m…

  9. 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…

  10. 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…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837604/psn-pdf
    June 29, 2022 - Diagnostic overshadowing among groups experiencing health disparities. June 29, 2022 Sentinel Event Alert. June 22, 2022;(65):1-7. https://psnet.ahrq.gov/issue/diagnostic-overshadowing-among-groups-experiencing-health-disparities A clinician's knowledge of an existing condition can implicitly affect treatment reco…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60706/psn-pdf
    July 22, 2020 - Painting a picture of nurse presenteeism: a multi-country integrative review. July 22, 2020 Freeling M, Rainbow JG, Chamberlain D. Painting a picture of nurse presenteeism: a multi-country integrative review. Int J Nurs Stud. 2020;109:103659. doi:10.1016/j.ijnurstu.2020.103659. https://psnet.ahrq.gov/issue/paintin…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60997/psn-pdf
    October 07, 2020 - ‘You’re going to release him when he was hurting himself?’ October 7, 2020 Dahlberg B. Kaiser Health News. September 29, 2020. https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself This story discusses failures related emergency psychiatric assessment, including premature discharge, imp…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47342/psn-pdf
    August 22, 2018 - The doctor doesn't listen to her. But the media is starting to. August 22, 2018 Fetters A. The Atlantic. August 10, 2018. https://psnet.ahrq.gov/issue/doctor-doesnt-listen-her-media-starting Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high- profile accoun…

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46882/psn-pdf
    May 23, 2018 - How health care changes when algorithms start making diagnoses. May 23, 2018 Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018. https://psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses Use of artificial intelligence and computer algorithms as tools to improve diagnosis have both r…

  18. 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…

  19. 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…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72583/psn-pdf
    December 16, 2020 - Wear face masks with no metal during MRI exams. December 16, 2020 FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020. https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams Magnetic resonance imaging (MRI) requires patient prep…
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