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5301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47696/psn-pdf
      February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…

5302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44565/psn-pdf
      October 14, 2015 - How to use online clinician rating systems. October 14, 2015 Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA. 2015;314(13):1418. doi:10.1001/jama.2015.11957. https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems Clinician rating sites may not always pr…

5303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36785/psn-pdf
      March 04, 2011 - Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. March 4, 2011 Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the…

5304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47056/psn-pdf
      April 20, 2022 - Healthcare Simulation Week. April 20, 2022 Society for Simulation in Healthcare. https://psnet.ahrq.gov/issue/healthcare-simulation-week Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials f…

5305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43621/psn-pdf
      October 22, 2014 - Multidisciplinary in-hospital teams improve patient outcomes: a review. October 22, 2014 Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int. 2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612. https://psnet.ahrq.gov/issue/multidisciplinary-hospital-teams-improve…

5306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46557/psn-pdf
      November 22, 2017 - Safe handover. November 22, 2017 Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328. https://psnet.ahrq.gov/issue/safe-handover Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, produ…

5307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34882/psn-pdf
      February 28, 2011 - Fumbled handoffs: one dropped ball after another. February 28, 2011 Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358. https://psnet.ahrq.gov/issue/fumbled-handoffs-one-dropped-ball-after-another This case study discusses the chain of events surrounding the delayed dia…

5308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837076/psn-pdf
      May 11, 2022 - AHRQ Challenge on Innovative Solutions To Update or Re-Create TeamSTEPPS Videos. May 11, 2022 Rockville, MD; Agency for Healthcare Research and Quality: April 2022. https://psnet.ahrq.gov/issue/ahrq-challenge-innovative-solutions-update-or-re-create-teamstepps-videos TeamSTEPPS promotes effective teamwork, collabo…

5309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60587/psn-pdf
      June 10, 2020 - Person-Centered Guidelines for Preserving Family Presence in Challenging Times. June 10, 2020 Derby, CT: Planetree; 2020. https://psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times Families have an important role in keeping patients safe. This book provides a set of patien…

5310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44700/psn-pdf
      March 23, 2016 - Factors that drive team participation in surgical safety checks: a prospective study. March 23, 2016 Gillespie BM, Withers TK, Lavin J, et al. Factors that drive team participation in surgical safety checks: a prospective study. Patient Saf Surg. 2016;10:3. doi:10.1186/s13037-015-0090-5. https://psnet.ahrq.gov/iss…

5311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37793/psn-pdf
      February 15, 2011 - Educating seniors to be patient safety self-advocates in primary care. February 15, 2011 Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806. https://psnet.ahrq.gov/issue/educating-seniors-be-patien…

5312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47533/psn-pdf
      June 19, 2019 - Patient Safety: A Health Affairs Briefing. June 19, 2019 Project Hope. https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study aimed at improving health care and reducing medical error. This in-person a…

5313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41307/psn-pdf
      May 04, 2012 - Development and validation of a tool to assess emergency physicians' nontechnical skills. May 4, 2012 Flowerdew L, Brown R, Vincent CA, et al. Development and validation of a tool to assess emergency physicians' nontechnical skills. Ann Emerg Med. 2012;59(5):376-385.e4. doi:10.1016/j.annemergmed.2011.11.022. http…

5314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37393/psn-pdf
      June 13, 2011 - Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit. June 13, 2011 Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care Unit. J Patient Saf. 2008;3(4). doi:1…

5315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42861/psn-pdf
      January 15, 2014 - Transitioning Newborns From NICU to Home: A Resource Toolkit. January 15, 2014 Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF. https://psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit Infants discharged from the neonatal intensiv…

5316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50643/psn-pdf
      November 06, 2019 - Same Day Surgery in the US; Findings of Two Inaugural Leapfrog Surveys 2019. November 6, 2019 Washington DC: Leapfrog Group; 2019. https://psnet.ahrq.gov/issue/same-day-surgery-us-findings-two-inaugural-leapfrog-surveys-2019 Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of …

5317. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
      September 24, 2024 - patient safety. 2 Efforts were led from the top, with the chief executive officer of the hospital system communicating

5318. Disclosure of Medical Error | PSNet
      psnet.ahrq.gov/perspective/disclosure-medical-error
      January 01, 2009 - July 8, 2020 Inpatient Notes: mistakes in the hospital—communicating, apologizing, and

5319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46880/psn-pdf
      April 25, 2018 - A culture of civility: positively impacting practice and patient safety. April 25, 2018 Makic MBF. A Culture of Civility: Positively Impacting Practice and Patient Safety. J Perianesth Nurs. 2018;33(2):220-222. doi:10.1016/j.jopan.2017.12.006. https://psnet.ahrq.gov/issue/culture-civility-positively-impacting-prac…

5320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73379/psn-pdf
      June 09, 2021 - How medical jargon can make COVID health disparities even worse. June 9, 2021 Kritz F. Health Shots. National Public Radio; May 24, 2021. https://psnet.ahrq.gov/issue/how-medical-jargon-can-make-covid-health-disparities-even-worse Health literacy efforts address challenges related to both language and effecti…