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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36425/psn-pdfDecember 22, 2010 - Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. December 22, 2010 Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med. 2006;130(11):1662-1668. https://p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74095/psn-pdfFebruary 01, 2022 - Zero Suicide Initiative. November 17, 2021 Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893. https://psnet.ahrq.gov/issue/zero-suicide-initiative Patient suicide attempts are considered never events. This funding announcement calls for pr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43560/psn-pdfSeptember 24, 2014 - Burnout in Healthcare. September 24, 2014 Laschinger H, Montgomery A, eds. Burnout Res. 2014;1:57-102. https://psnet.ahrq.gov/issue/burnout-healthcare Burnout has been linked to depression, work dissatisfaction, and increased rates of adverse events. Articles in this special issue explore health professionals' exp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47354/psn-pdfNovember 21, 2018 - Improving Diagnosis in Medicine Change Package. November 21, 2018 Chicago, IL: Health Research & Educational Trust; 2018. https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45442/psn-pdfOctober 12, 2016 - Radiotherapy Incident Reporting and Analysis System. October 12, 2016 Center for Assessment of Radiological Sciences. 4913 Wuakesha Street, Madison,WI 53705. 608-345- 5795. Email: brthomad@cars-pso.org. https://psnet.ahrq.gov/issue/radiotherapy-incident-reporting-and-analysis-system Patient Safety Organizations en… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36622/psn-pdfJanuary 14, 2011 - Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. January 14, 2011 Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. Am J Clin Pathol. 2007;127(1):144-52. https://psnet.ahrq.gov/issue/measu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43375/psn-pdfJuly 23, 2014 - Managing risk at the point-of-care: preventing errors. July 23, 2014 Njoroge S; Nichols JH. https://psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action and laboratory staff performing the analys… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73451/psn-pdfJune 30, 2021 - National Patient Safety Syllabus. June 30, 2021 Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021. https://psnet.ahrq.gov/issue/national-patient-safety-syllabus Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a challenge. This st… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37086/psn-pdfOctober 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. October 3, 2011 Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37858/psn-pdfJune 25, 2008 - Measuring team performance in healthcare: review of research and implications for patient safety. June 25, 2008 Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.1016/j.jcrc.2007.12.005. https://psnet.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34719/psn-pdfDecember 23, 2008 - Learning from samples of one or fewer. December 23, 2008 March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465- 472.) https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer Organizations learn from experience. However, learning from rare events is challenging becau… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60563/psn-pdfJune 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35111/psn-pdfApril 06, 2011 - Patient safety features of clinical computer systems: questionnaire survey of GP views. April 6, 2011 Morris CJ, Savelyich BSP, Avery A, et al. Patient safety features of clinical computer systems: questionnaire survey of GP views. Qual Saf Health Care. 2005;14(3):164-8. https://psnet.ahrq.gov/issue/patient-safety… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34887/psn-pdfFebruary 26, 2009 - Has the Leapfrog Group had an impact on the health care market? February 26, 2009 Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood). 2005;24(1):228-33. https://psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market The Le… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836867/psn-pdfApril 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX; Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36041/psn-pdfJune 21, 2006 - Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. June 21, 2006 Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG. https://psnet.ahrq.gov/issue/intraoperative-adverse-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43718/psn-pdfDecember 03, 2014 - Patient safety culture in nephrology nurse practice settings: initial findings. December 3, 2014 Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476. https://psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings This study utilized AHRQ patient safety culture surveys to asse… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866357/psn-pdfJuly 24, 2024 - People’s Experiences of Diagnosis. July 24, 2024 People’s Experiences Of Diagnosis. London, England: National Voices; June 2024. https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnosti… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37564/psn-pdfJune 12, 2008 - The medical emergency team system: a two hospital comparison. June 12, 2008 Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison. Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016. https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36204/psn-pdfSeptember 30, 2010 - Automated medication error studies with audit supplementation were effectively designed and analyzed by time series. September 30, 2010 Shuster JJ, Winterstein AG. Automated medication error studies with audit supplementation were effectively designed and analyzed by time series. J Clin Epidemiol. 2006;59(9). doi…
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