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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837973/psn-pdf
    August 31, 2022 - Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff. August 31, 2022 Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff. PLoS ONE. 2022;17(6):e0269921. doi:10.1371/journal…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35374/psn-pdf
    January 02, 2017 - Intimidation: practitioners speak up about this unresolved problem. January 2, 2017 Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4. https://psnet.ahrq.gov/issue/intimidation-practitioners-s…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44736/psn-pdf
    December 16, 2015 - Harms from discharge to primary care: mixed methods analysis of incident reports. December 16, 2015 Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687877. https://psnet.ahrq.gov/is…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74858/psn-pdf
    February 23, 2022 - Improving responses to safety incidents: we need to talk about justice. February 23, 2022 Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333. https://psnet.ahrq.gov/issue/improving-responses-safety-in…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838623/psn-pdf
    October 19, 2022 - Resident and nurse perspectives on the use of secure text messaging systems. October 19, 2022 Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953. https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40177/psn-pdf
    June 08, 2011 - Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. June 8, 2011 Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8. doi:1…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43485/psn-pdf
    December 15, 2014 - Implementation of an emergency department sign-out checklist improves transfer of information at shift change. December 15, 2014 Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg Med. 2014;47(5):580-5. doi:10…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865974/psn-pdf
    May 29, 2024 - Minimizing bias when using artificial intelligence in critical care medicine. May 29, 2024 Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796. https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39614/psn-pdf
    June 18, 2021 - Preventing violence in the health care setting. June 18, 2021 Preventing violence in the health care setting. Sentinel Event Alert. 2010;(45):1-3. https://psnet.ahrq.gov/issue/preventing-violence-health-care-setting Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853233/psn-pdf
    September 06, 2023 - Weight estimation for drug dose calculations in the prehospital setting - a systematic review. September 6, 2023 Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027. htt…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47456/psn-pdf
    April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. April 30, 2019 Horsham, PA: Institute for Safe Medication Practices; 2018. https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices Standardized practices have not been uniformly adopted to support safe IV medicati…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46479/psn-pdf
    October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts. October 4, 2017 Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395. https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts Applying evidence generated from complaints submitted to h…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44170/psn-pdf
    May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety Culture. May 29, 2023 Rockville, MD: Agency for Healthcare Research and Quality; October 2020. https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73077/psn-pdf
    March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44330/psn-pdf
    September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop Summary. September 2, 2015 Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN: 9780309371544. https://psnet.…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45028/psn-pdf
    May 25, 2016 - 'Just culture': improving safety by achieving substantive, procedural and restorative justice. May 25, 2016 Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018. https://psnet.ahrq.gov/issue/just-cultu…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39840/psn-pdf
    September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems for prevention. September 15, 2010 Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45035/psn-pdf
    January 23, 2017 - Premature closure? Not so fast. January 23, 2017 Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016- 005267. https://psnet.ahrq.gov/issue/premature-closure-not-so-fast Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39356/psn-pdf
    April 08, 2011 - Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. April 8, 2011 Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48028/psn-pdf
    August 28, 2019 - Error Reduction and Prevention in Surgical Pathology, Second Edition. August 28, 2019 Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636. https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition Surgical specimen and laboratory process proble…

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