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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45058/psn-pdf
    February 18, 2017 - Learning from incidents in healthcare: the journey, not the arrival, matters. February 18, 2017 Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. https://psnet.ahrq.gov/issue/learni…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43458/psn-pdf
    August 27, 2014 - Validation of a teamwork perceptions measure to increase patient safety. August 27, 2014 Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942. https://psnet.ahrq.gov/issue/validation-teamwork…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867347/psn-pdf
    December 11, 2024 - Recommendations to ensure safety of AI in real-world clinical care. December 11, 2024 Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598. https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41449/psn-pdf
    February 13, 2019 - Just Culture and its critical link to patient safety—part 1 and part 2. February 13, 2019 ISMP Medication Safety Alert! Acute Care Edition. May 17, 2012;17:1-4; July 12, 2012;17:1-3. https://psnet.ahrq.gov/issue/just-culture-and-its-critical-link-patient-safety-part-1-and-part-2 This newsletter article series pres…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36664/psn-pdf
    May 27, 2011 - A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. May 27, 2011 Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Saf Sci. 2006;45(4).…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36087/psn-pdf
    September 28, 2010 - Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory. September 28, 2010 Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory. Health Serv Res. 2006;41(4 Pt 2):1654-76. https://psnet.ah…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38346/psn-pdf
    April 01, 2010 - Human factors engineering in healthcare systems: the problem of human error and accident management. April 1, 2010 Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005. http…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41453/psn-pdf
    November 26, 2014 - Judging whether a patient is actually improving: more pitfalls from the science of human perception. November 26, 2014 Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33926/psn-pdf
    March 07, 2005 - The problems of detecting medication errors in hospitals. March 7, 2005 Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360. https://psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals Perhaps the f…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35022/psn-pdf
    June 22, 2009 - The investigation and analysis of critical incidents and adverse events in healthcare. June 22, 2009 Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii. https://psnet.ahrq.gov/issue/in…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45492/psn-pdf
    September 28, 2016 - Understanding human over-reliance on technology. September 28, 2016 ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4. https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47320/psn-pdf
    September 05, 2018 - Patient safety climate: a study of Southern California healthcare organizations. September 5, 2018 Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004. https://psnet.ahrq.gov/issue/patient-safety…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41738/psn-pdf
    June 10, 2018 - Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4. https://psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk- infections This articl…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35043/psn-pdf
    June 22, 2009 - Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. June 22, 2009 Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. J Biomed Inform. 2005;38(3):213-9. https://psnet.ahrq.gov/issue/human-factors-e…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47504/psn-pdf
    December 21, 2018 - Health apps and health policy: what is needed? December 21, 2018 Bates DW, Landman A, Levine DM. Health Apps and Health Policy: What Is Needed? JAMA. 2018;320(19):1975-1976. doi:10.1001/jama.2018.14378. https://psnet.ahrq.gov/issue/health-apps-and-health-policy-what-needed Mobile health care applications are incre…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35235/psn-pdf
    September 27, 2017 - What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors. September 27, 2017 Grasso BC, Rothschild JM, Jordan CW, et al. What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors. J Psychiatr Pract. 20…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60531/psn-pdf
    May 27, 2020 - Telenursing in incidents and disasters: a systematic review of the literature. May 27, 2020 Nejadshafiee M, Bahaadinbeigy K, Kazemi M, et al. Telenursing in incidents and disasters: a systematic review of the literature. J Emerg Nurs. 2020. doi:10.1016/j.jen.2020.03.005. https://psnet.ahrq.gov/issue/telenursing-in…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46331/psn-pdf
    September 14, 2018 - Health IT Patient Safety Supplemental Items for Hospitals. September 14, 2018 Agency for Healthcare Research and Quality. July 25, 2018.  https://psnet.ahrq.gov/issue/health-it-patient-safety-supplemental-items-hospitals Tracking the intersection of organizational culture with health information technology use can …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37966/psn-pdf
    January 15, 2009 - Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. January 15, 2009 Ludwick DA, Doucette J. Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45789/psn-pdf
    January 11, 2017 - Concurrent and Overlapping Surgeries: Additional Measures Warranted. January 11, 2017 US Senate Finance Committee. December 6, 2016. https://psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted The practice of scheduling concurrent surgeries has raised concerns about increased ri…
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