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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47775/psn-pdf
    April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic management teams. April 3, 2019 Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121. https://psnet.ahrq.gov/issue/reducing-diagnostic-error…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46562/psn-pdf
    April 16, 2018 - "To err is human" but disclosure must be taught: a simulation-based assessment study. April 16, 2018 Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation- Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.0000000000000273. https://psnet.ahrq.g…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38544/psn-pdf
    September 02, 2009 - A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. September 2, 2009 Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-5. do…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47583/psn-pdf
    December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. December 5, 2018 Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704. https://psnet.ahrq.gov/…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852278/psn-pdf
    August 09, 2023 - Identifying failure modes in telemedicine: an instructional needs assessment. August 9, 2023 Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365. https://psnet.ahrq.gov/issue/identif…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46663/psn-pdf
    November 29, 2017 - ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5. https://psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety Texting medication orders is convenient …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45506/psn-pdf
    November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46611/psn-pdf
    January 01, 2021 - Sustaining teamwork behaviors through reinforcement of TeamSTEPPS principles. November 15, 2017 Lee S-H, Khanuja HS, Blanding RJ, et al. Sustaining Teamwork Behaviors Through Reinforcement of TeamSTEPPS Principles. J Patient Saf. 2021;17(7):e582-e586. doi:10.1097/pts.0000000000000414. https://psnet.ahrq.gov/issue/…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855437/psn-pdf
    November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. November 15, 2023 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937. https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42539/psn-pdf
    September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73452/psn-pdf
    June 30, 2021 - Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021 ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5. https://psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still- deadly Concentrated …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853436/psn-pdf
    September 13, 2023 - Long-term sustainability and adaptation of I-PASS handovers. September 13, 2023 Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007. https://psnet.ahrq.gov/issue/long-term-sustainability-and-ada…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852286/psn-pdf
    August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023. August 9, 2023 Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262. https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73365/psn-pdf
    June 09, 2021 - Enhancing psychological safety in mental health services. June 9, 2021 Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1. https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50590/psn-pdf
    January 01, 2020 - Patient and family engagement as a potential approach for improving patient safety: a systematic review. October 30, 2019 Park M, Giap T-T-T. Patient and family engagement as a potential approach for improving patient safety: A systematic review. J Adv Nurs. 2020;76(1):62-80. doi:10.1111/jan.14227. https://psnet.a…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44002/psn-pdf
    March 25, 2015 - Preventing medication errors in transitions of care: a patient case approach. March 25, 2015 Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509. https://psnet.ahrq.gov/issue/prevent…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…

  18. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. | PSNet

    psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73963/psn-pdf
    October 13, 2021 - Patient perceptions of safety in primary care: a qualitative study to inform care. October 13, 2021 Lasser EC, Heughan JA-A, Lai AY, et al. Patient perceptions of safety in primary care: a qualitative study to inform care. Curr Med Res Opin. 2021;37(11):1991-1999. doi:10.1080/03007995.2021.1976736. https://psnet.a…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854383/psn-pdf
    January 01, 2024 - What can safety cases offer for patient safety? A multisite case study. October 11, 2023 Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042. https://psnet.ahrq.gov/issue/what-can-safety-cases…
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