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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36170/psn-pdf
    December 30, 2012 - Standardizing safety. December 30, 2012 Meyers S. Standardizing safety. Trustee. 2006;59(7):12-4, 21, 1. https://psnet.ahrq.gov/issue/standardizing-safety The author describes how several hospitals implemented crew resource management programs to improve communication. https://psnet.ahrq.gov/issue/standardizing-s…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40347/psn-pdf
    April 06, 2011 - Delivering results. April 6, 2011 Landro L. Wall Street Journal. March 28, 2011. https://psnet.ahrq.gov/issue/delivering-results This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies. https://psnet.ahrq.gov/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37866/psn-pdf
    June 25, 2008 - National safety effort targets perinatal injuries. June 25, 2008 O'Reilly KB. https://psnet.ahrq.gov/issue/national-safety-effort-targets-perinatal-injuries This article reports on an initiative to prevent birth injuries through improved communication techniques and evidence-based care interventions. https://psne…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35903/psn-pdf
    May 04, 2015 - Costly issues of an uncommunicative OR. May 4, 2015 Neil R. Costly issues of an uncommunicative OR. Materials management in health care. 2006;15(3):30-3. https://psnet.ahrq.gov/issue/costly-issues-uncommunicative-or This article discusses initiatives for better communication and teamwork in the operating room in or…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35362/psn-pdf
    September 28, 2005 - Managing the aftermath of iatrogenic injury. September 28, 2005 Vincent C; Saunders A. https://psnet.ahrq.gov/issue/managing-aftermath-iatrogenic-injury The authors discuss how harmful mistakes affect both staff and patients. They recommend open communication with and possible psychological support for those invol…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36840/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-11 This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values. https://…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42392/psn-pdf
    June 26, 2013 - The drawbacks of data-driven medicine. June 26, 2013 Gunderman R. The Atlantic. June 5, 2013. https://psnet.ahrq.gov/issue/drawbacks-data-driven-medicine This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or c…

  8. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
    November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…

  9. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet

    psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
    January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022  Also Read the Essay Citation Text: In Conversation With.…

  10. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet

    psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD | November 16, 2022  Also Read the Conversation View more articles from the same aut…

  11. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet

    psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
    January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41550/psn-pdf
    March 22, 2014 - An infection, unnoticed, turns unstoppable. March 22, 2014 Dwyer J. New York Times. July 11, 2012:A15. https://psnet.ahrq.gov/issue/infection-unnoticed-turns-unstoppable This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death. https://psnet.ahrq.gov/issu…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39058/psn-pdf
    October 28, 2009 - Obstetric Quality and Safety. October 28, 2009 J Healthc Qual. 2009;31:3-52. https://psnet.ahrq.gov/issue/obstetric-quality-and-safety Articles in this special issue cover numerous aspects of patient safety in obstetric care: teamwork training, simulation, communication, and process improvement strategies. https:…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36120/psn-pdf
    January 04, 2009 - Risk Management Pearls on Disclosure of Adverse Events. January 4, 2009 Amori GH. Chicago, IL: American Society for Healthcare Risk Management; 2006. https://psnet.ahrq.gov/issue/risk-management-pearls-disclosure-adverse-events This booklet shares scenarios and strategies for effective communication during disclos…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36534/psn-pdf
    March 09, 2009 - Standardizing hand-off processes. March 9, 2009 Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61. https://psnet.ahrq.gov/issue/standardizing-hand-processes The author suggests ways to improve hand-off communications and provides an assessment form to assist staff in detecting weaknesses in…

  16. Volume Too Low: In and Out | PSNet

    psnet.ahrq.gov/web-mm/volume-too-low-and-out
    July 01, 2017 - SPOTLIGHT CASE Volume Too Low: In and Out Citation Text: Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49506/psn-pdf
    March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/wet-read Case Objectives Appreciate the limitations of radiology resident emergency coverage. Understand the rate of discrepancy between radiology resident preliminary reads and attending radiologists' fina…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33784/psn-pdf
    April 01, 2015 - In Conversation With… David Urbach, MD, MSc April 1, 2015 In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation at the University…

  19. Obstetrician-gynecologist views of pregnancy-related medication safety. | PSNet

    psnet.ahrq.gov/issue/obstetrician-gynecologist-views-pregnancy-related-medication-safety
    July 29, 2020 - Study Obstetrician-gynecologist views of pregnancy-related medication safety. Citation Text: SteelFisher GK, Hero JO, Caporello HL, et al. Obstetrician-gynecologist views of pregnancy-related medication safety. J Womens Health (Larchmt). 2020;29(8):1113-1121. doi:10.1089/jwh.2019.8007. …

  20. Medication errors among adults and children with cancer in the outpatient setting. | PSNet

    psnet.ahrq.gov/issue/medication-errors-among-adults-and-children-cancer-outpatient-setting
    January 16, 2010 - Study Medication errors among adults and children with cancer in the outpatient setting. Citation Text: Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol. 2009;27(6):891-6. doi:10.1200/JCO.2008.18.60…
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