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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38747/psn-pdf
    September 16, 2009 - Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture. September 16, 2009 Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844793/psn-pdf
    September 11, 2019 - PC standards for maternal safety. September 11, 2019 The Joint Commission. R3 Report. August 21, 2019;24:1-6. https://psnet.ahrq.gov/issue/pc-standards-maternal-safety Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Pro…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45263/psn-pdf
    September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35402/psn-pdf
    September 10, 2009 - Can patients be part of the solution? Views on their role in preventing medical errors. September 10, 2009 Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing medical errors. Med Care Res Rev. 2005;62(5):601-16. https://psnet.ahrq.gov/issue/can-patients-be…

  5. 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…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46298/psn-pdf
    October 18, 2017 - CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy. October 18, 2017 Kuang C. Fast Company. October 4, 2017. https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy Complicated systems often require more than one change to improve their s…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40097/psn-pdf
    January 19, 2011 - Use of an electronic information system to identify adverse events resulting in an emergency department visit. January 19, 2011 Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50905/psn-pdf
    February 19, 2020 - Patient activation related to fall prevention: a multisite study February 19, 2020 Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study . Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010. https://psnet.ahrq.gov/issue/patient-activation-relat…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45251/psn-pdf
    August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong? August 24, 2016 Kowalczyk L. Boston Globe. August 14, 2016. https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series o…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46510/psn-pdf
    January 01, 2019 - Pediatric weight errors and resultant medication dosing errors in the emergency department. November 22, 2017 Hirata KM, Kang AH, Ramirez G, et al. Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department. Pediatr Emerg Care. 2019;35(9):637-642. doi:10.1097/PEC.0000000000001277. …

  11. 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-…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45275/psn-pdf
    November 01, 2017 - Electronic tools to support medication reconciliation—a systematic review. November 1, 2017 Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068. https://psnet.ahrq.gov/issue/electronic-tools-s…

  13. 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…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74117/psn-pdf
    December 16, 2021 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals. November 24, 2021 Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021. https://psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals The release of the Workplace Safety supplemental items for…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837626/psn-pdf
    July 06, 2022 - Frailty, gaps in care coordination, and preventable adverse events. July 6, 2022 Akinyelure OP, Colvin CL, Sterling MR, et al. Frailty, gaps in care coordination, and preventable adverse events. BMC Geriatr. 2022;22(1):476. doi:10.1186/s12877-022-03164-7. https://psnet.ahrq.gov/issue/frailty-gaps-care-coordination…

  16. 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…

  17. 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…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60764/psn-pdf
    August 05, 2020 - As coronavirus ravaged nursing homes, inspectors were not being tested. August 5, 2020 Dolan J, Mejia B. As coronavirus ravaged nursing homes, inspectors were not being tested. Los Angeles Times. 2020;July 24. https://psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested Worker s…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47213/psn-pdf
    June 20, 2018 - Are second victims getting the help they need? June 20, 2018 Headley M. Patient Saf Qual Healthc. May/June 2018. https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building p…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867049/psn-pdf
    October 30, 2024 - National Review of Maternity Services in England 2022 to 2024. October 30, 2024 National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality Commission; September 2024. https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024 Maternal safety is a gl…
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