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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38287/psn-pdf
    February 06, 2009 - Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. February 6, 2009 Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-51. doi:10.1111/j.1399-6576.2008.01717.x. https://psnet.ahrq.gov/iss…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36180/psn-pdf
    September 29, 2010 - Why nurses make medication errors: a simulation study. September 29, 2010 Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007;27(4):312-7. https://psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study The investigators used a simulate…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41476/psn-pdf
    June 20, 2012 - Interdisciplinary team training: five lessons learned. June 20, 2012 Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47- 52. doi:10.1097/01.NAJ.0000415127.84605.1f. https://psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned This commen…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42185/psn-pdf
    April 10, 2013 - Improving patient safety in medicine: is the model of anaesthesia care enough? April 10, 2013 Haller G. Improving patient safety in medicine: is the model of anaesthesia care enough? Swiss Med Wkly. 2013;143:w13770. doi:10.4414/smw.2013.13770. https://psnet.ahrq.gov/issue/improving-patient-safety-medicine-model-an…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844558/psn-pdf
    January 13, 2024 - On Patient Safety. January 13, 2024 Tingle J. Br J Nurs. 2001-2024. https://psnet.ahrq.gov/issue/patient-safety-19 This series of commentaries discusses a wide range of policy, legal, and operational topics related to patient safety in the British health system, such as artificial intelligence, patient communicati…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46151/psn-pdf
    May 24, 2017 - The last person you'd expect to die in childbirth. May 24, 2017 Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017. https://psnet.ahrq.gov/issue/last-person-youd-expect-die-childbirth Maternal mortality is increasing in the United States. This news article reports on this critical safety probl…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42757/psn-pdf
    November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector. November 20, 2013 Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013. https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector Following the implementation of a large clinical information communicati…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74193/psn-pdf
    December 15, 2021 - Input for the TeamSTEPPS Curriculum Updates. December 15, 2021 Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021. https://psnet.ahrq.gov/issue/input-teamstepps-curriculum-updates The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39068/psn-pdf
    October 28, 2009 - Four patients say Cedars-Sinai did not tell them they had received a radiation overdose. October 28, 2009 Zarembo A. https://psnet.ahrq.gov/issue/four-patients-say-cedars-sinai-did-not-tell-them-they-had-received-radiation- overdose This news piece describes communication gaps following a radiation overdose incid…
  10. psnet.ahrq.gov/web-mm/not-miscarriage
    June 01, 2005 - Not a Miscarriage Citation Text: Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  11. psnet.ahrq.gov/web-mm/it-safe-be-direct
    September 30, 2015 - Is It Safe to Be Direct? Citation Text: Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49772/psn-pdf
    October 01, 2016 - Lapse in Antibiotics Leads to Sepsis October 1, 2016 Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis The Case A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and short…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853772/psn-pdf
    September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…
  14. psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
    August 30, 2023 - Strategies to Improve Organizational Health Literacy. Citation Text: Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format:…
  15. psnet.ahrq.gov/web-mm/misleading-complaint
    December 01, 2009 - Misleading Complaint Citation Text: Soni K, Dhaliwal G. Misleading Complaint. 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 …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50843/psn-pdf
    January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…
  17. psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
    October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836791/psn-pdf
    August 21, 2024 - TeamSTEPPS for Diagnosis Improvement. August 21, 2024 TeamSTEPPS for Diagnosis Improvement. https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new Te…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44226/psn-pdf
    November 03, 2015 - The Patient Survival Handbook. November 3, 2015 Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015. https://psnet.ahrq.gov/issue/patient-survival-handbook Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74766/psn-pdf
    June 24, 2024 - Patient handoffs. June 24, 2024 Arora V, Farnan J. UpToDate. June 24, 2024. https://psnet.ahrq.gov/issue/patient-handoffs-0 The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issu…

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