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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42626/psn-pdfOctober 02, 2013 - Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. October 2, 2013 Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification of Missing Safety Barriers Using t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50706/psn-pdfDecember 04, 2019 - Improving end-of-rotation transitions of care among ICU patients December 4, 2019 Denson JL, Knoeckel J, Kjerengtroen S, et al. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf. 2019;29(3):250-259. doi:10.1136/bmjqs-2019-009867. https://psnet.ahrq.gov/issue/improving-end-rotation-tran… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43780/psn-pdfSeptember 09, 2015 - Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors. September 9, 2015 Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofes… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44950/psn-pdfMarch 02, 2016 - Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets. March 2, 2016 Schwartz A, Weiner SJ, Binns-Calvey A, et al. Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46184/psn-pdfJanuary 01, 2018 - A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. December 19, 2017 Parand A, Faiella G, Franklin BD, et al. A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. Ergonomics. 2018;61(1):104… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72482/psn-pdfNovember 18, 2020 - Real-time debriefing after critical events: exploring the gap between principle and reality. November 18, 2020 Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between principle and reality. Anesthesiol Clin. 2020;38(4):801-820. doi:10.1016/j.anclin.2020.08.003. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46579/psn-pdfApril 11, 2018 - Electronic medicine can send you test results quickly. But what if they're scary? April 11, 2018 Boodman SG. Washington Post. March 26, 2018. https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary Although providing patients with access to physician notes and test r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844545/psn-pdfFebruary 15, 2023 - Providers' and patients' perspectives on diagnostic errors in the acute care setting. February 15, 2023 Schnock KO, Garber A, Fraser H, et al. Providers' and patients' perspectives on diagnostic errors in the acute care setting. Jt Comm J Qual Patient Saf. 2023;49(2):89-97. doi:10.1016/j.jcjq.2022.11.009. https://… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/858165/psn-pdfDecember 13, 2023 - When public health goes wrong: toward a new concept of public health error. December 13, 2023 Bavli I. When public health goes wrong: toward a new concept of public health error. J Law Med Ethics. 2023;51(2):385-402. doi:10.1017/jme.2023.67. https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-con… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838911/psn-pdfOctober 26, 2022 - Medication adverse events in the ambulatory setting: a mixed-methods analysis. October 26, 2022 Wong J, Lee S-Y, Sarkar U, et al. Medication adverse events in the ambulatory setting: a mixed-methods analysis. Am J Health Syst Pharm. 2022;79(24):2230-2243. doi:10.1093/ajhp/zxac253. https://psnet.ahrq.gov/issue/medi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43703/psn-pdfDecember 19, 2014 - Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? December 19, 2014 Shin MH, Sullivan JL, Rosen AK, et al. Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73863/psn-pdfSeptember 22, 2021 - Electronic health record interoperability-why electronically discontinued medications are still dispensed. September 22, 2021 Shervani S, Madden W, Gleason LJ. Electronic health record interoperability-why electronically discontinued medications are still dispensed. JAMA Intern Med. 2021;181(10):1383-1384. doi:10… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47693/psn-pdfJanuary 23, 2019 - Solving alarm fatigue with smartphone technology. January 23, 2019 Short K, Chung YJ. Solving alarm fatigue with smartphone technology. Nursing (Brux). 2019;49(1):52-57. doi:10.1097/01.NURSE.0000549728.37810.d9. https://psnet.ahrq.gov/issue/solving-alarm-fatigue-smartphone-technology Alarm fatigue contributes to d… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865706/psn-pdfMay 01, 2024 - Stigmatizing language, patient demographics, and errors in the diagnostic process. May 1, 2024 Brooks KC, Raffel KE, Chia D, et al. Stigmatizing language, patient demographics, and errors in the diagnostic process. JAMA Intern Med. 2024;184(6):704-706. doi:10.1001/jamainternmed.2024.0705. https://psnet.ahrq.gov/is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838924/psn-pdfOctober 26, 2022 - Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. October 26, 2022 Wu G, Podlinski L, Wang C, et al. Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. Jt Comm J Qual Patient Saf. 2022;48(12):665-6… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35361/psn-pdfJuly 16, 2009 - Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. July 16, 2009 Wu HW, Nishimi RY, Page-Lopez CM, et al. Washington DC: National Quality Forum; 2005. https://psnet.ahrq.gov/issue/improving-patient-safety-through-informed-consent-patients-limited-health- literacy In the 2… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47841/psn-pdfApril 24, 2019 - Criminalisation of unintentional error in healthcare in the UK: a perspective from New Zealand. April 24, 2019 Ameratunga R, Klonin H, Vaughan J, et al. Criminalisation of unintentional error in healthcare in the UK: a perspective from New Zealand. BMJ. 2019;364:l706. doi:10.1136/bmj.l706. https://psnet.ahrq.gov/i… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73595/psn-pdfAugust 11, 2021 - Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021 ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5. https://psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838145/psn-pdfSeptember 21, 2022 - Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them. September 21, 2022 Donovan-Smith O. Spokesman-Review. September 11, 2022. https://psnet.ahrq.gov/issue/charlie-bourg-was-lookout-veterans-harmed-new-va-computer-system-he- didnt-expect-be-one… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50686/psn-pdfJanuary 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. November 20, 2019 Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure while guarding p…
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