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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38102/psn-pdf
    April 15, 2019 - Epidemiology of adverse events in air medical transport. April 15, 2019 MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15(10):923-931. doi:10.1111/j.1553-2712.2008.00241.x. https://psnet.ahrq.gov/issue/epidemiology-adverse-events-air-medical-transpo…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45840/psn-pdf
    February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866621/psn-pdf
    August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - Double Dosing, by the Rules March 21, 2009 Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/double-dosing-rules The Case A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was admitted to a medical unit during the night with wo…

  5. Comanagement: Who's in Charge? | PSNet

    psnet.ahrq.gov/web-mm/comanagement-whos-charge
    July 01, 2011 - Comanagement: Who's in Charge? Citation Text: Cheng HQ. Comanagement: Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38742/psn-pdf
    January 03, 2017 - Implementing a team-based daily goals sheet in a non-ICU setting. January 3, 2017 Holzmueller CG, Timmel J, Kent P, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8, 341. https://psnet.ahrq.gov/issue/implementing-team-based-daily-goals-sheet-non-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47966/psn-pdf
    May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39342/psn-pdf
    March 03, 2010 - Discharge missteps can send seniors back to hospital. March 3, 2010 Korc B, Landers SJ. American Medical News. February 15, 2010. https://psnet.ahrq.gov/issue/discharge-missteps-can-send-seniors-back-hospital This news article uses an example of a preventable readmission to illustrate how ineffective communication …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42869/psn-pdf
    January 28, 2017 - Exploring Alternatives To Malpractice Litigation. January 28, 2017 Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66. https://psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation Articles in this special issue cover findings from a federally-funded initiativ…

  10. Deciphering the Code | PSNet

    psnet.ahrq.gov/web-mm/deciphering-code
    November 16, 2022 - Deciphering the Code Citation Text: Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  11. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet

    psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
    January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Citation Text: Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? April 29, 2020 Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…

  13. Empty Handoff | PSNet

    psnet.ahrq.gov/web-mm/empty-handoff
    August 01, 2017 - Empty Handoff Citation Text: Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49501/psn-pdf
    February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…

  16. Patient and Family Engagement in Long Term Care | PSNet

    psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
    April 10, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient and Family Engagement in Long Term Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, C…

  17. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/866984
    January 01, 2020 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Interdisciplinary teamwork Curated Library Foundations Medical teamwork and the evolution of safety science: a critical review. Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27. In this narrative review, the authors contr…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72831/psn-pdf
    March 10, 2021 - Enhancing a culture of safety through disclosure of adverse events. March 10, 2021 Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27 https://psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events Error disclosure is supported by a robust safety …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44789/psn-pdf
    April 25, 2016 - Guideline for prevention of retained surgical items. April 25, 2016 Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102(6):P11-P13. https://psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items Retained surgical items are considered a sentinel event in perioperative care. Thi…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46334/psn-pdf
    August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…
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